How to Prepare For the End of Patient Care

By Caitlyn Rose, OTR/L
Occupational Therapist

From the beginning of our plan of care, we should have the end goal in mind. But how do you know when? I know I struggle with knowing the appropriate time to transition my cases. There are times I feel like I could continue treatment indefinitely. You know the cases—the progressive disorders, the chronic diseases, our patients with chronic pain from arthritis, or a past medical history of multiple surgeries. But we all need to know when to “take a break.”

9 Questions Clinicians Should Ask Before Ending Patient Care

There is a lot that clinicians must keep in mind during our plan of care. Below is a list of questions to consider in preparation for a timely end to patient care.

1. Where Can I Go for Support With Ending Patient Care?

Reach out to your team: the physical therapist/occupational therapist/speech-language pathologist on the case, your regional director (or manager), fellow colleague, or quality assurance liaison.

I find talking out loud with my colleagues helps me separate facts from feelings and enables me to make better clinical decisions. Do not be afraid to reach out to your quality assurance liaison and/or regional director (or manager) for input, too.

Don’t forget to loop in the patient and caregiver as well. Consider asking your patients and caregivers how confident they are with specific training or exercises using a 1-10 scale. This can help you, the patient, and the caregiver gauge their comfort level with the training you have provided to date. What concerns, questions, priorities, or goals remain? Are there any new priorities or goals since beginning your plan of care?

2. What Are My Patient’s Current Medical Needs?

There must be a unique or complex need impacting the patient in a specific, functional manner that requires skilled care.

Review your initial evaluation. Are you still treating with the original intention that initiated your services? If not, why? Is a re-evaluation or re-certification a better clinical decision than ending treatment altogether? If not, and maintenance is not an option, what is keeping you from ending your skilled care at this time?

3. Is There Enough Skilled Need?

Are there enough goals? Are there too many goals? Remember, we need to be realistic and efficient.

Some red flags that tell me it may be time to discontinue treatment include repeated exercises, cueing, handling techniques, even behavioral management strategies. If there is no more progress in the sense of increased postural challenges, added resistance, increased sets or repetitions, what skills remain? Are our patients still active participants, or are they just going through the motions? Are you just going through the motions? If you are bored, your patient probably is, too.

4. How Can I Make Ending Patient Care as Efficient as Possible?

Let’s respect each other’s time and resources (yes, I mean insurance).

Consider performing the PSFS – Patient-Specific Functional Scale. Use the results to prioritize what is most important to the patient. Don’t waste your time or that of your patient or their caregiver.

5. Does My Patient Need Restorative or Maintenance Therapy?

This is most helpful for your complex cases—patients with one or more chronic diseases who need ongoing therapy over the years. Therapy is to be intermittent, not continuous.

Reviewing the Jimmo vs. Kathleen Sebelius class action settlement can be helpful in situations where our patients may be concerned about the ability to continue therapy due to a lack of progress. All of our patients are entitled to continued care without the need to demonstrate progress, BUT! the continued care must be medically necessary and skilled.

Restorative: Otherwise known as “traditional” services that attempt to reverse a loss of function.

Maintenance: For patients who are so medically complex a caregiver cannot safely care for them, there is still a medical need for our services.

Our services still need to be skilled. What barriers are there keeping a caregiver from being trainable?

6. What Are the Barriers to Continued, Medically Necessary, Skilled Care?

Some barriers include when a caregiver is not reliable due to lack of motivation, lack of time, lack of cognitive ability. For example, a caregiver who has physical, emotional, or cognitive impairments of their own. Unfortunately, just because a caregiver is not available does not mean the patient can qualify for continued skilled care. Remind yourself that as clinicians, we are not responsible for taking on the role of the caregiver. Our job is to train the patient or caregiver.

7. How Can You Ensure an Easy Transition From Care?

Ensure your patient and caregivers are aware of their local community support and resources such as meals on wheels, accessible transportation, private home health aid companies, exercise physiologists, and social workers.

Depending on your region and your patient’s needs, maybe a local outpatient therapy clinic or fitness center to keep active, a yoga studio for stress management, or have your patient sign up to try Dance for Parkinson’s or Rock Steady Parkinson’s boxing classes. Sometimes a support group is a helpful addition, too. Don’t forget to check out your community hospitals, senior centers, and libraries for information courses and support groups!

Sometimes, complementary and alternative medicine is a good option, especially for those in chronic pain.

8. How Can You Help Taper Services?

Consider your current dosage. Can you adjust your frequency or duration? For example, start treating your patients early in the plan of care 3x/wk, then gradually taper down to 2x/wk, to 1x/wk, to every other week, to monthly check-ins, if appropriate. This is especially helpful for the more complex cases who have been receiving your care for an extensive amount of time and are anxious about discontinuing treatment. Knowing care will be gradually weaned may bring some comfort and relief, and time for planning, if necessary. Some cases may require time to put a more permanent solution in place in terms of support in the home—anything from grab bar installation to hiring 24-hour assistance. You can be a part of this transition.

For instance, if someone needs to modify a bathroom or bedroom, consider holding care for a week or two and returning after the installation is complete in order to train the patient and caregiver on the new environment and equipment, then follow up a week later to ensure the patient and caregiver are comfortable and have no further questions or concerns.

9. How and When Should You Communicate Discontinuing Services With Patients?

How do we empower our patients to get involved with their own transition from skilled care? How much “heads-up” should we give them and their caregivers?

Communicate the plan of care right from the initial evaluation. After my evaluations, when I ask the patients and caregivers if there are any questions, one of the very first questions I tend to hear is “how long will you be treating?” Take this opportunity to do a little education. Discuss the anticipated date to end services, standardized assessments, and routine progress reports, as well as the potential for re-certification, if appropriate. Talk about transitions and planning for the end of care. Always start your cases with the end in mind, and make sure your vision is in line with that of each of your patients’!

Be S.M.A.R.T. — Ensure your goals are Specific, Measurable, Attainable, Realistic, and Timely!

Perform a weekly update. Informally re-assess the patient’s goals and progress made so far. Are you addressing all the patient and caregiver’s therapeutic needs? Do you need to adjust your plan of care at all?

One tip is to set up a monthly calendar. Some families are very organized and will already have a well-used calendar waiting for you while other families may need some support in this area. Sometimes we are called in because a patient or caregiver is overwhelmed and is looking for this kind of support. Set up a calendar and place it somewhere noticeable—the refrigerator, for instance. Refer to the calendar at the beginning and end of every session, if need be.

Home exercise programs and caregiver training should start early and happen often. Keep in mind the communication preferences and learning styles of the patient and caregiver. Once the patient or caregiver is educated and trained in all areas of skilled need to manage the patient’s functional needs, it is time to end care.

And So We End Patient Care—For Now

We all have to at some point…but when? Stay objective. Reach out to your team, patient, and caregivers. Review the patient’s medical and skilled needs, functional ability, and ensure the caregiver has been trained. Consider your treatment plan, including possible referrals to community resources. Remember to be S.M.A.R.T. and efficient. Start your treatment plan from the beginning of your plan of care, communicate, educate, and train the patient and family early and often, continuously re-assess, and adjust your plan of care as necessary.

I know I struggle with when to discontinue treatment for certain patients, but remember to stay objective.