When to discharge a patient?

When to Discharge a patient

Many allied health professionals believe in ‘life-time’ care so discharging a patient may seem foreign. This is founded on the ‘wellness’ or maintenance way of thinking or a structured rehabilitative plan that leads to ongoing lifestyle management.

There are times, however, discharging is an entirely appropriate option and needs to give consideration.

In this article I focus on when to discharge a patient in an allied health care environment.

Private patients.

The private patient, in the first instant, presents to the allied health professional to help resolve a condition. The initial consent process relates to the initial treatment schedule and that includes numerous treatments and costs.

In my experience few private patients are deliberating about what happens once their condition has been resolved. It is the practitioner who imparts their particular philosophy of care in reasonable and clinically justifiable treatment options.

Some practitioners choose to discharge their patients once symptoms and signs have abated, and the patient can reasonably resume managing their health.  Other practitioners believe relevant health education and periodic check-ups can help patients manage their health better, thus preventing acute relapse.

Oftentimes our patients self-discharge with or without conversation with the treating practitioner. This can be due to various reasons from, financial constraints, time and logistical factors, dissatisfaction with treatment outcomes, mis-matched expectations, e.g., treatment taking longer than expected a preference to move to another professional service, pre-existing beliefs around their own health and particular professions etc. In my experience this is the norm, i.e., few patients take the time to have a conversation around considering self-discharge. This could be through fear of confrontation, embarrassment, intimidation etc., or that the practitioner has not provided adequate space during the consultation to establish a health enquiry and consent as an ongoing process.

Consent is an ongoing concern particularly if our treatment recommendations fall beyond initial care. An ongoing dialogue not only builds rapport, but it also potentially reduces early self-discharge. It also creates the space for the patient to discuss concerns along the way that may lead to a discharge conversation. This then provides the opportunity to refer to another professional rather than discharge the patient completely from the health process.

If your treatment plan is to continue treatment after the initial process, this needs to clinically justify. Each and every visit needs to be clinically justifiable.

Jason T. Smith, founder of the Back In Motion Health group, the largest Physiotherapy group in Australia and N.Z. has formulated what he calls, the ‘Results 4 Life’ process. This, effectively, takes the patient thru a journey that goes beyond mere resolution of pain. Jason believes in proactive care where the patient is provided with a structured, clinically justified treatment plan including exercise prescription, rehabilitation, clinical pilate etc. to help patients not only ‘be better’ but ‘stay better’. [2]

Preventative / proactive care, also referred to as maintenance or wellness care, has been redefined in recent years by AHPRA (Australian Health practitioners regulation agency). AHPRA uses the term ‘periodic care’ where patients are encouraged to not delay treatment at the earliest onset of signs and symptoms. [1]  AHPRA’s advertising guidelines states, a breach would involve encouraging a person to attend periodic or regular appointments where there is no clinical indication to do so. This includes contracting for future services.[1]

Private patients, therefore, may be discharged in the following circumstances:

Self-elected discharge with or without full resolution of presenting condition and with or without consultation with the treating practitioner.

Practitioners elected discharge due to poor clinical outcomes warranting appropriate referral to another more suitable health professional or full cessation of initial pain and other symptoms.

The practitioner elected discharge from initial treatment on a technical basis as the patient is moved to the next, rehabilitative phase.

It is possible a patient may never be fully discharged, e.g., chronic health conditions, internal referral, chronic negative lifestyle influences or a desire to maintain a positive treatment approach to maintain optimal health and manage the earliest onset of symptoms, e.g., 6 wkly myotherapy, physiotherapy or chiropractic treatments.

The 3rd party patient.

This includes Medicare care plans, TAC, Workcover, DVA and other 3rd party payers.

3rd party insurers and payers expect patients to be discharged once pain and other symptoms have been suitably resolved. This may mean on-referral, e.g., exercise physiology or a personal trainer, however, there must be an end in sight. If the practice provides rehabilitative services then discharge may be extended however, at some reasonable point in time, this must happen.

In some instances, the patient may elect to become a private patient and continue treatment for other unrelated and possibly less urgent conditions, but this can only occur once the patient is discharged from the 3rd party process.

Conclusion:

It is imperative we educate our patients to not delay care and present at the earliest onset of symptoms. It is important each and every consolation is clinically justified including extending treatment beyond resolution of initial pain and symptoms. It is plausible a patient may never be fully discharged. It is also plausible a patient may elect to early self-discharge before they reach an optimal outcome.

References:

[1] https://www.ahpra.gov.au/publications/advertising-hub/advertising-guidelines-and-other-guidance/advertising-guidelines.aspx

[2] Smith, J.T. https://jasontsmith.com.au/

About the author:

Dr Andrew Arnold is founder of Million Dollar Wellness and director, Back In Motion Cranbourne.

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