On “Physical therapy information: could it reduce hospital 30-day readmissions?” Kreppein J, Stewart TD. Phys Ther. 2014;94:1680–1682.

Kreppein and Stewart¹ raise a timely and important issue: the 30-day readmission rate among hospitals and the role that the physical therapist contributes in reducing the readmission rate. The 30-day readmission rate is a measure of the unplanned all-cause patient readmissions to any acute care hospital within the 30 days after discharge from a hospital. This measure was initiated in 2012, and the Centers for Medicare & Medicaid Services (CMS) applies a payment adjustment (reduction) to hospitals with excessive readmissions.²

Discharge planning is the process that facilitates the patient's transition from the hospital back to the community, such as a return to home or a placement in a facility that provides inpatient care and physical therapist services. This process is complex, concerns about patients' unmet needs are longstanding,³ and tangible benefits from the discharge planning process rarely are evident.⁴ This is further complicated by the low mobility and bed rest that patients experience when hospitalized and the associated adverse outcomes after discharge, such as falls.⁵ One quarter to one half of the hospitalized older population has functional loss during hospitalization, and only one third recover to prehospital levels of functioning after 3 months.⁶

We agree with Kreppein and Stewart that physical therapists provide valuable input into the discharge disposition that should be used when gauging readmission risk. Smith et al⁷ found that “Holding all other variables constant, a patient was more likely to be readmitted when the therapist discharge recommendation was not implemented and services were lacking compared with patients with a match” of services and needs.⁸ This is a strong endorsement for the value of the physical therapist's recommendations within the process of developing a discharge plan.

This is no easy task; the physical therapist's contribution to discharge planning is based on a dynamic process of sophisticated clinical decision making and with a focus on patient safety and functioning.^9–11 Checklists can frame issues that should be considered in this process,^12,13 but effective clinical decision making relies on the physical therapist's “assessment within the context of the patients' functioning and disability, wants and needs, ability to participate in care, and life context.”^9(p224)

We agree that, despite evidence identifying value, the voice of the physical therapist is too often missing in the discharge planning process. This may be due to barriers to physical therapists' contributing to discharge planning in hospitals. Anecdotal reports suggest that barriers include staffing reductions that decrease physical therapist services among some inpatient populations, and physical therapist discharge plan recommendations that are not accepted or followed by other members of the health care team. Our personal recommendation is that advocacy by physical therapists practicing in hospitals is needed to raise the therapist's profile in the discharge planning process.

Advocacy, even when supported by evidence, is a daunting process in the complex hospital environment. The American Physical Therapy Association provides resources (http://www.apta.org/HospitalReadmissions), including an audio course titled The Value of Physical Therapy in Reducing Avoidable Hospital Readmissions,¹⁴ for therapists who are working to have their voice appreciated in the discharge planning process.

Transitions of care can be difficult for patients, and additional evidence is needed to inform and to streamline the process for achieving optimal outcomes. Additional research is needed to improve patient management and to inform the therapist's contributions to a discharge planning process that effectively reduces 30-day readmission rates.

• © 2015 American Physical Therapy Association