Hospitals often forget physical-therapy instructions to nursing homes

Madison, Wis. — Patients recovering from stroke and broken bones usually need physical therapy, but a new study suggests that hospital personnel frequently forget to provide physical-therapy instructions when the patients leave for nursing-home rehabilitation.

An analysis of Medicare data from 2006 to 2008 by University of Wisconsin-Madison geriatrics researchers found that physical-therapy recommendations were missing from discharge orders at one large medical center between 53 and 100 percent of the time, depending on the type of recommendation.

Not only do these omissions cause gaps in care, but Medicare data suggest that patients who went to the nursing home without physical-therapy orders fare more poorly, and were more likely to be re-admitted to the hospital.

“It’s a problem of communicating, and it creates real issues for our patients,” says Dr. Amy Kind, associate professor of medicine and a geriatrics expert who led the study. “In my opinion, health-care quality comes from simple things being done well. If we don’t do a better job of communicating, our patients may not have the best outcomes.”

First author Brock Polnaszek says that while a study at one medical center is not generalizable, the issue of improving communications between health care locations was the topic of a symposium at the American Geriatrics Society’s annual research meeting this year.

“The best analogy is to think of it as individual silos of health care that are not connected,” he says. “We send the patient out from one silo and don’t do a very good job at connecting them to their next destination.”

The study, published in the Archives of Physical Medicine and Rehabilitation, looked at 302 stroke patients and 315 bone-fracture patients who were sent from the hospital to nursing homes between 2006 and 2008. Out of 611 discharge orders, physical-therapy orders were complete only in three instances.

Kind says the idea for the research came from focus groups of nurses from nursing homes. In that earlier qualitative study, nurses reported that they were not getting therapy orders and as a result, the patients were not getting their therapy.

Polnazek, now a third-year medical student at the University of Wisconsin School of Medicine and Public Health, says he has suggested some different approaches to medical-student education based on the studies.

“I’ve learned that as medical students, we need more exposure to the problems our patients will face when they are outside the hospital,” he says. “I’ve also suggested that we get more training with other specialists such as physical therapists.”

At University of Wisconsin Hospital and Clinics, Kind says she and others have implemented a new system, using electronic medical records, that automatically sends recommendations from physical therapists, dieticians and others into the discharge orders that go with a patient to a nursing home.

“We worked to develop some interventions to improve discharge orders,” says Kind, who does her research at the Geriatric Research, Education and Clinical Center (GRECC) at the William S. Middleton Memorial Veterans Hospital and has helped develop better discharge protocols for the VA hospital system.