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Discharging Issues in SNF

  •  09-25-2012, 12:53 AM

    Discharging Issues in SNF

    I am in a big discussion with my coworkers on what is an appropriate discharge for a SNF patient returning to home.  PLOF is completely independent for BADLs and IADLs and community mobility.  Initially, she was at a max/dep level due to medical issues and depression.  She is currently at SBA level with BADLs and SBA for home mgmt and meal prep. Her main problem is poor endurance and balance issues.  Basically, I was told by the PTA that she is at the level she is going to be at on their end for mobility with FWW at mod I and without a device at SBA.  I disagree and feel that we should push her to be as independent as possible since she has no financial means to hire assist and her family can't assist much since they work.  The PTA tells me that the family will have to deal with the problems at home since she is not needing skilled services.  I want to work more on the IADLs and also working on a toileting program to help transition her to being more continent at home also.  I was pressured by higher ups to d/c since she is likely to get denied if we continue her treatment that it is something that the outpatient level can deal with.  I argue that we write in our evals that the goal is to be independent and we haven't even met it and then we turn around say she has to go home with assist.  She continues to show potential to improve and be at her PLOF also which leads me to push her more.  I don't see why we should just give up and make her family have to bear the burden when we can intervene and improve the resident and decrease her burden of care.  Am I just being stubborn or what do you all think about this?
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