COPD, Type 2 Diabetes, and early MCI are each independently associated with extended post-acute stays and elevated readmission risk. Together, they create a compounding profile. Respiratory tolerance will limit therapy intensity — Margaret cannot sustain the standard 60+ min/day PT/OT cadence without risk of COPD exacerbation, so a slower progression paced to O2 sat and perceived exertion is indicated. Diabetes complicates wound healing and increases infection risk at the surgical site, requiring daily monitoring that her Assisted Living can provide but a home health agency may not visit frequently enough to catch. The early cognitive decline (CDR 0.5) means care instructions must be simplified, routines kept consistent, and family communication prioritized — her daughter is a key information bridge but is not a daily caregiver. Recommended: SNF admission for skilled care, target 14–21 days, with warm handoff protocol to AL memory support team at discharge.

Robert presents a straightforward post-acute profile. Hypertension and hyperlipidemia are both medically managed and do not significantly complicate TKA recovery. Full pre-op ADL independence at 80 is a strong predictor of return-to-baseline function within 45 days. The presence of a capable, full-time spousal caregiver at home substantially reduces readmission risk — research consistently shows that caregiver presence is one of the strongest protective factors in post-surgical orthopedic recovery. His FIM of 104 at discharge indicates near-normal functional baseline restored. Recommended: Direct home health discharge, PT 3×/week for 6 weeks, standard orthopedic protocol. No SNF admission indicated. Expected return to prior activity level by Day 45.