Resource Center

Discharge planning begins on admission when a patient enters a short-term care facility for rehabilitation from joint replacement. This will include a plan to return into the community setting be it to a private home, personal care home or assisted living facility.

As part of the discharge plan, the interdisciplinary team members will work together to plan for the clinical needs, any equipment needs and any additional community services that may be needed once the patient returns home. Appropriate team members will communicate with the patient's physician, durable medical equipment companies and additional home health agencies and/or outpatient therapy departments to provide the patient with all the necessary tools to continue rehabilitation and optimal functionality once returning to the community environment.

After the patient has reached all goals and desired outcomes at the facility level of rehabilitation the team is prepared to assist the patient with returning to the community. This may include but not be limited to:

• Obtaining physician orders for equipment needed, medications and treatments needed at home
• Scheduling for equipment set up in home environment
• Transportation home
• Home assessment to establish safety and equipment issues
• Scheduling home health assessment
• Scheduling outpatient therapy appointments
• Scheduling physician follow up appointments.

Returning to the community after joint replacement can be a slow process for many. The information provided here can assist a patient facing joint replacement the ability to understand the process and options associated with surgical replacement of a damaged joint.

Understanding can facilitate a conversation with the patient's physician – knowing what questions to ask – which in turn will provide the patient a means to make an educated decision based on physician recommendation and desired outcomes.