A major goal of all SW/CM programs is to work with
the patient and family toward a safe discharge back to
the home environment. Efforts are put forth to optimize
living environments, ensure adequate availability and
training of caregivers, obtain equipment, and secure
necessary financing for needed services. For some
patients, especially those with stable family situations,
developing and implementing the plan for a home discharge
generally goes smoothly. For other patients, the
plan may become more tenuous as the rehabilitation
course progresses and the patient may end up not
being discharged to home.
Of all activities included in the SW/CM taxonomy,
the two that were delivered to almost all patients and in which most time was spent, were discharge planning
and discharge services.6 Time spent in these activities
was associated significantly with multiple outcomes.
Because the topics contained within these two activities
were numerous and diverse (Table 2), we identified the
mean duration and number of sessions in which each
sub-topic was addressed. In the discharge planning
activity, the most common services were planning for
a home discharge and addressing barriers; less
common services included planning for discharge to
locations other than home. Topics included in the discharge
services activity were more similar, but still identified
different areas of need. Thus, we allowed the
number of sessions in which each topic of the discharge
planning and discharge services activities to serve as
additional independent variables in regression models