An elderly man with a hip fracture and THR is admitted to a skilled nursing facility for rehabilitation and intends to return home. What is the MOST appropriate action for the therapist?

An elderly man with a hip fracture and THR is admitted to a skilled nursing facility for rehabilitation and intends to return home. What is the MOST appropriate action for the therapist?

• A. Advise the family that the patient should determine his own discharge environment
• B. Recommend a team conference with the patient and his family to discuss discharge plans
• C. Schedule a home visit to determine if home modifications are needed before discharge
• D. Implement a treatment plan with a long term goal of discharge to home

Answer: (B)

Collaborative discharge planning with active patient and family involvement is essential when an older adult with a hip fracture and a total hip replacement prepares to leave rehab. Convening a team conference brings together the rehabilitation professionals, nursing, social work, and the patient and family to discuss goals, prognosis, safety, and support needs at home. This ensures the patient’s preferences are honored, potential barriers are identified, and a coherent plan—covering home modifications, equipment, caregiver support, and follow-up therapy—can be arranged before discharge. While a home visit can be valuable to assess the actual environment, it should be planned after the goals and needs have been clarified in a multidisciplinary discussion. Rushing to set a long-term home discharge as the sole action neglects the collaborative planning necessary for a safe transition.

Collaborative discharge planning with active patient and family involvement is essential when an older adult with a hip fracture and a total hip replacement prepares to leave rehab. Convening a team conference brings together the rehabilitation professionals, nursing, social work, and the patient and family to discuss goals, prognosis, safety, and support needs at home. This ensures the patient’s preferences are honored, potential barriers are identified, and a coherent plan—covering home modifications, equipment, caregiver support, and follow-up therapy—can be arranged before discharge. While a home visit can be valuable to assess the actual environment, it should be planned after the goals and needs have been clarified in a multidisciplinary discussion. Rushing to set a long-term home discharge as the sole action neglects the collaborative planning necessary for a safe transition.