These words elicit a wide range of emotions based on to whom they’re being spoken and the preparedness of the responsible parties, including the discharge planner, the patient’s family, and, of course, the patient himself.
The discharge planner silently chuckles with doubt as she sits in the multidisciplinary rounds and hears these words from the powers that be, knowing full well the ensuing challenges of a successful discharge within 24 hours. The family members nod in cautious agreement while reeling with fear of the unknown. Who will care for their loved one? What services will he need? What costs will be incurred? The patient is either excited, clueless, or filled with trepidation.
Those of us who share the title of Case Manager, Care Manager, Discharge Planner, etc. and are licensed as a Registered Nurse or Social Worker are part of a club that’s small but elite, powerful yet not always respected, and resourceful but often lacking necessary resources. We’d all agree there are basically three types of discharges: Piece of Cake, Bit of a Challenge, and the Total Train Wreck. While we all love those Piece of Cake patients with the perfect, loving, caring family and a simple medication cocktail ordered at discharge, we also know that the Challenge and Train Wreck discharges are imminent and will require time, energy, and patience.
Increasing Complexity
We’re working in an environment riddled with uncertainty, constantly changing regulations, and more ‘disruptive’ new government and private payer initiatives than ever before; including the ‘volume to value’ conundrum, which instructs us to prevent inappropriate admissions and readmissions while at the same time understanding that ‘heads on beds’ yields money and, frankly, our job security. The Centers for Medicare and Medicaid Services’ (CMS) 30-day readmission penalties are at the forefront of hospital executives’ agendas due to the significant financial penalties they can potentially impose on a hospital.
Furthermore, as a result of the evolving trend towards ambulatory care, the vast majority of hospital inpatient admissions are those with very clinically complex conditions. Yet, hospitals continue to carefully monitor lengths of stay to optimize reimbursement, which further complicates the discharge process and shortens the amount of time the case manager has to create a safe and efficient transition to the next level of care, whether that be to a long-term acute care facility, a skilled nursing facility, or home with some level of professional or custodial support.
To further support the radical changes in the industry, CMS is proposing amendments to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which defines initiatives and measures to improve the quality of post-acute care. According to CMS, “The IMPACT Act requires hospitals, critical access hospitals, and certain post-acute care providers to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences.” Participation in the Medicare and Medicaid programs will be dependent on aligning with these new requirements.
So, where do we go from here? A quick Discharge 101 lesson will confirm the challenges those of us in the field face every day, and should also help those unfamiliar with the process understand the complexities and roadblocks we face in facilitating transitions along the care continuum.
The formula for a successful discharge plan:
• Is initiated immediately upon admission through a comprehensive assessment of the patient’s needs, including family support, living arrangements, equipment needs to help with activities of daily living (ADLs), financial considerations, and insurance coverage
• Considers not only the patient’s medical and emotional needs, but also the social determinants that impact the discharge in ways that are often grossly underestimated
• Has buy-in from the patient, family, and medical team
Once the plan is established, it’s time to execute the various action items. This is where the ‘fun’ comes in for the discharge planner. Imagine Freddie, our ‘Bit of a Challenge’ patient who was admitted on Monday, and according to the medical team, is ready for discharge Friday. Freddie is a 91-year-old, feisty gentleman with a history of COPD, degenerative disc disease, and diabetes. To top it off, Freddie lives alone in a two-story house, has family who occasionally checks on him, relies on the city bus system for transportation, and enjoys his bourbon. The case manager is tasked with taking each of these considerations into account and formulating a plan that will enable a safe discharge and prevent a readmission. (And, by the way, we are held accountable for inappropriate readmissions and are measured against this metric in our reviews!)
Freddie will need the following minimal level of services to successfully transition out of the hospital:
• Home Health Care: RN to monitor for medication adherence, check vitals, etc.; a dietician to advise on his food intake to manage the diabetes and coach him on the effects of alcohol on his blood sugar; and PT/OT to perform a home-safety evaluation and educate him on the importance of a safe exercise routine
• Durable Medical Equipment: Oxygen due to his worsening COPD; a wheeled walker; diabetic supplies
• Home Care (Private Duty): Nurse’s aide to assist Freddie with bathing, cooking, shopping, finances, etc.
• Transportation and other ancillary support services: Referral to the Area Agency on Aging
Keep in mind that Freddie isn’t even a Train Wreck patient, and he’s only one of 15-20+ patients on the case manager’s census who needs to be followed throughout the admission.
The Right Resources
So, it’s no surprise that the discharge is a lengthy, complicated, and often stressful process and that it is typically left to the case manager to coordinate all of these care interventions and services. Unfortunately, while we possess strong critical thinking skills and are multi-tasking masters, we lack the tools necessary to effectively perform our responsibilities.
If you speak with any care manager, you’ll find that with all the increased legislation, measurement and oversight, their responsibilities have drastically increased – while there are still only so many hours in a day. What many people may not know is that there is hope on the horizon. There are now innovative software and database applications that have the power to streamline and organize information – helping you to identify the most appropriate next level of care with just a few clicks rather than spending hours of research and coordination. With the right technology, we can expect to have more Pieces of Cake, and fewer Train Wrecks!
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.