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Written by: Darlene D'Altorio-Jones (1959-2015) on Saturday, January 14, 2012 Posted in: Inpatient Rehab

I don’t think I really ever challenged this statement.  It just made sense.  If you don’t believe the statement, refer to the mathematical evidence made available on a Google search and posted by Patrick Blochle, Canisius College, Buffalo, NY.

Yet, every day when witnessing the path from admit to discharge by a patient in rehabilitation, I don’t often see evidence of this straight and narrow approach.  The interdisciplinary team may not have the exact requirements for discharge fully identified; making it hard for every caregiver to reach that specific level to enable a successful discharge in a timely direct fashion.  Reaching the discharge goals as quickly as possible requires the entire team to be focused on the straight line.

Sure, staff complete evaluations that define impairments and resource gaps.   Each patient has their own subset of impairment and their own subset of available resources.  Clinicians provide evaluations to identify the various impairments/conditions.  These evaluations provide information on functional capability and limitations, along with ability to provide self care against expected capability in their own environment at discharge.  Then through experience and knowledge, clinicians create individual plans to attain a specific functional level.   The team conference should substantiate those individual goals and work toward the interdisciplinary goal statements.

As patient learning is achieved, it must be exercised by the interdisciplinary team to create meaningful carryover at all times in a normal day-to-day fashion.   There should be enough overlap to enable the patient sufficient practice to feel competent and safe once discharged.  It’s expected 24/7 for an IRF/IRU rehabilitation level of care.

In retrospect, these outline to some degree what the World Health Organization defines in an International Classification of Function. A  model view and explanation is available in a beginner’s guide on its website.


The rehabilitation that our plans of care must address is the connection to the specific type of impairment (health condition or contextual factor), that enables the patient to return home given the resources available to them.  The quickest path to meeting the requirement is knowing the discharge expectation so that every encounter of the interdisciplinary team is addressed collaboratively for discharge.  This creates the straight line; a common discharge expectation.

Given the level of function that can be handled upon discharge by the patient or caregiver,  the plans of care must all be designed in the specific disciplines to support attainment of that criteria.

It means that continuous practice, experience and coordination of care must build on each others’ successes so that the strength of the patient and eventual caregivers, if required, are all capable of meeting the participation level expected.

The line should be as straight as possible so that effective, efficient and focused care is provided.  Although highly individualized to meet specific resource capability, the straight and narrow should always point toward the discharge expectation.

When the expected level of one area is achieved, time and resources should point to the areas most resistant so everyone is focused on improving those items through supported practice.  To do this, it must be apparent on the progress that has been made and which areas lag behind.  It must always be referencing present status to expected outcome – always keeping the entire team on the straight line toward discharge.  Shortest distance is important; the value of care will be defined by meeting objectives in the least costly manner.  Adopting these expectations provides an efficient model to meet those expectations

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