Guidance on Plans of Care & Discharge Planning

Dear LifeCare Therapists,

After reviewing our plans of care and visit frequencies, we have developed updated guidance to address the challenge of patients remaining on extended care plans. Our goal is to support you in delivering excellent care while ensuring timely and appropriate discharges.

Initial Plan of Care Recommendations

• For new patients, please start with a plan of care (POC) for 16 or fewer visits. We always ask that you use your clinical judgment, so there is no "minimum" number of therapy visits you need to recommend; however, we do want to be realistic in how much therapy a patient can/should receive. This provides an opportunity to assess patient compliance and response, allowing POCs to be adjusted accordingly.

• If a patient's therapy plan of care requires recertification, the maximum number of visits should be 24. There must be mitigating circumstances, or it will otherwise be difficult to document "substantial improvement in a reasonable period of time".

• Increasing therapy frequency to 3x/week, when possible, has shown significant improvements in patient outcomes. For more information, see our related blog post here.

Multidisciplinary Approach

• We encourage a multidisciplinary approach. Complete one discipline’s plan of care before starting another, and communicate when a patient is ready for the next discipline.

• When appropriate, consider transitioning patients from physical therapy to occupational therapy, with a focus on self-care, activities of daily living (ADLs), and functional mobility/safety at home.

Discharge Planning

• At the end of each plan of care, use the discharge recommendation printout (you can access that here) and refer patients back to their physicians for follow-up. This ensures their doctor is involved in the next steps and can evaluate the patient’s progress. Discharge should never be a surprise - communication is key to successful outcomes and happy patients!

• Physicians generally do not expect outpatient therapy to continue for extended periods unless medically necessary. They appreciate seeing the results of our therapy over time.

Home Exercise Programs (HEP)

• Home exercise programs should be introduced and discussed with patients, caregivers, and families from the very first session. ptMantra is an online HEP program that monitors patient compliance and is available for all therapists and patients.

• Therapy assistants should review HEP at every visit to ensure patients are prepared for discharge and understand their ongoing exercise plan.

Maintenance and Titration

Titration from a therapy plan of care is always an option to help transition a patient to an independent home program. For example, in a 16-visit POC, the patient can be seen 2 x 6 (12 visits) and then 1 x 4. Always do what is best for the patient.

Maintenance therapy is a covered benefit, but requires specific criteria to be met. LifeCare does not advocate for "year-round" therapy in most cases and tries to implement options, including alternating disciplines, returning to the physician, and seeking other long-term care options. We are recommending 12-visit maintenance therapy programs at initiation as a guideline (1 x 12 weeks) to assess benefit and need. You can learn more about the requirements for maintenance therapy by reading this blog.

Our Commitment

We are proud of our talented team of therapists and the high-quality care you provide. As we move forward, let’s focus on effective discharges so we can continue to serve new patients in need.

If you have questions about maintenance or long-term patients, or if you believe a patient is ready for discharge, a break in care, or a transition to another discipline, please reach out for a care review. We are here to support you.

Thank you for your dedication and commitment to our patients!