Transition and Discontinuation
When transition starts
Transition planning begins at evaluation, not on the last day. Know the continuum: acute care, inpatient rehabilitation, skilled nursing, home health, outpatient, and community day programs. The COTA contributes observations and recommendations; the OT and team finalize discharge destination and the discontinuation summary.
Elements of the plan
Caregiver training verified with teach-back, home safety and accessibility review, equipment prescription and fitting, community resources and DME funding, medication and appointment routines, transportation, fall prevention, emergency planning, and self-advocacy. Document who was trained, by what method, and how competence was confirmed.
Discontinuation criteria
Goals met, no further functional benefit (plateau), patient refusal, nonattendance, reimbursement limits, or a change in medical status. Plateau is not automatic discharge - consult the OT to revise goals or the approach first. A COTA does not independently discontinue services.
Trap: the option that stops services because the patient "plateaued" without attempting modification, or that finalizes a plan without training the caregiver.
Worked example: After a hip replacement a patient is safe with a walker on level surfaces but cannot manage the three steps into their apartment, and no caregiver is available. Appropriate action: flag the barrier in team communication, recommend step-management training and a home safety evaluation, and discuss a temporary alternative setting - not discharge home simply because ADLs are met.
Rule of thumb: discharge destination follows the environment, not the diagnosis.