Is It Time to Discharge? 10 Steps to Clarity.
Are you struggling with knowing if it’s time to discharge a pediatric patient? Do you feel unsure if the family or your supervisor will approve? Use this checklist to feel more confident in your decision.
1. Go back to the initial evaluation and review their performance, goals and behaviors.
This will give you a good starting place to determine the progress the child has (or has not) made. It’s easy to forget how far a child has come from that very first evaluation. I’ve done plenty of evaluations on children that were absolutely wild and could not complete any type of standardized testing- the whole evaluation had to be done via parental interview and clinical observations.
Generally these kids settle into a routine and are far more capable than that first eval demonstrated! It can also lead to an open conversation with the parents, reminding them how much improvement their child has already made.
2. Review the most recent evaluation and do a comparison of the two.
Has the child made progress within the standardized test? (This is what insurance is looking at). Be sure to look at the context of fine motor, visual motor, behavior, activities of daily living (ADL) status, etc. What I mean by this is, even if he’s gone up multiple points on the part of the test evaluating manual dexterity- is it functional progress? Is he dropping things less? Utilizing an appropriate grasp, etc. The test doesn’t mean anything if the child is not capable of carrying the skills over to his everyday life.
Review how much progress she made on long term goals. You can make a thousand short term goals the child will achieve quickly, but is he/she chipping away at that long term goal?
Also, is the family consistent about completing the Home Exercise Program (HEP)? How do you know? Are they returning ‘homework’? Are they showing you pictures or videos of them using strategies you provided? Or do they always have the same answer when you ask about it? “Oh, he’s doing fine at home.” “Well, you know we try, but she doesn’t like to do it.”, etc. That will give you a pretty good barometer of how hard the family is working with the child at home.
I don’t say this to put any family down because day to day life with a special needs child is work in and of itself. But if they are coming to therapy 1 or 2 times a week and expecting miracles to happen, well, we know how that will turn out.
3. Review ADL status, both in therapy sessions and at home with parents.
This is important because it demonstrates how functional the child actually is. I’ve had several kiddos who were capable of dressing themselves, of manipulating clothing fasteners, washing their hands and so forth, in the clinic, but the parents said they couldn’t or wouldn’t do these activities at home.
Clearly this can be frustrating for all involved but provides good information for you, as the therapist, to work with. You may need to bring the family into the session so they can see how the child performs, or you may need to change up the HEP to address these skills further. It can also be a sign that the kid has no carryover.
On the other hand, I find that when parents say this, they often do it all for the child. If the kiddo is completing these activities at home, then why are you still working on them in session? I find that ADL goals can be relatively quick to achieve if the parents are willing to enforce your strategies at home.
4. What is the diagnosis? Will they ALWAYS qualify for services?
Logically and ethically think through what that truly means and if they should even been in services forever. Have they ‘maxed out’ their potential at this stage?
Nobody likes to hear this one. But think about it. Some of these kids will always qualify for services. They will score poorly or be unable to perform standardized tests and will never meet their peer level. That’s hard to accept and likely harder to live with. These are often the kids who will stall out at some point and will have been going to occupational therapy FOR.EV.ER. yet make no progress.
5. How long has the child been in therapy? 6 months? Or closer to 6 years?
This relates to #4, if you have a kiddo that’s been in therapy for YEARS, with absolutely minimal progress, then you need to evaluate your own stance about what is ethical and what you believe as a therapist.
Personally, I do not believe occupational therapy is a lifelong sentence. I do not believe kids should receive therapy for years on end. It defies everything we strive for. As therapists, we are working towards facilitating independence in all areas of their life. Which means, they should not be dependent on us for that progress! I believe pediatric OT should be used as a boost to help solve specific problems and give the parents ideas on how to work with the child.
I know that’s controversial, but oh well, you have to stand up for what you believe is right.
6. Is the child engaging and actively learning and progressing through goals and milestones or have they shut down and started to become ‘behavioral’? Would they benefit from a 6 month (or longer) break in services?
Again, use your clinical reasoning skills. If this was once a well mannered kiddo who liked to play with you and was happy to see you, but is now purposefully wetting themselves, refusing participation or making up excuses to get out of therapy, they may be burnt out. I see this a lot in kids who’ve been coming to therapy for years and receive treatment from multiple disciplines (OT, PT, ST, ABA)
7. How old is the child and where is he/she developmentally?
This is gold. Even though a child may developmentally be 5 or 6, if their body is going through puberty, they will have all the hormones of a 16 year old. Obviously this can be a difficult time and you can look at either adjusting goals to address this or deciding if a break is best for the family so they can adjust.
8. What are the parental goals? Are they reasonable or could they be addressed with an HEP?
I’ve had kids I was thinking about discharging and when I would bring it up with the parents, they were against it, but had no goals for the kiddo! Then what was I doing? Undoubtedly you’ll have this situation come up where the parent wants the kid to continue receiving services, but they really don’t have a reason why.
Or sometimes you’ll get the response “to tie his shoes”. That’s it. I’m not one to limit a kids potential, but this is not worth spending hundred of dollars a month in insurance. There are so many options, velcro, slip ons, sandals, pull clasps, and so on, that a person does not have to know how to tie shoes! Also, what’s the point? Is it so they will fit in with peers, is it because the parents don’t want to buy slip on shoes? Dig deeper and see if you can’t find out what the real deal is.
Think ethically here, is it worth your license and possible fraud to keep requesting services for a kid who’s as typical and functional as they will likely ever be, but will never be able to tie their shoes?
9. Can you reduce their frequency or duration of services? (Say, cut down to 1 session per week) and continue to see results?
Just because insurance approved a 1 hour session, 2 x per week, doesn’t mean it’s what is best for the child. Talk to the parents about a trial of reduced frequency. See if he/she performs better knowing the session is shorter, or knowing they won’t have to see the therapist again until next week. Occasionally, this can make all the difference in a child’s performance and willingness to participate. Going to therapy becomes an outing and the therapist can facilitate this re-engagement by providing a wider variety of experiences and activities.
10. Trust your gut. If you think it is time for that child to move on, then say so. As therapists we have pretty good intuition when we allow ourselves to listen.
There’s some reason you believe this child should or should not be discharged. Hash it out with other therapists and be willing to accept their critiques and advice. Sometimes a kid is still making progress but it’s YOU who is burnt out on that kid or that family. Maybe instead of discharging them, see if another therapist is willing to treat them. Try shaking up the goals. Don’t discharge a kid ‘just because’, instead, take time to utilize your clinical reasoning skills and own motivation before making a change.