Creativity is the key to discharge planning for hard-to-place patients

Develop a relationship with skilled nursing facilities

Hospital discharge planners often have to use their ingenuity in finding placements for patients with no insurance who need post-acute services or are homeless and need a place to stay.

The problem is that patients must be discharged safely, whether or not they have money to pay for the services they need.

"Each case is slightly different, and we look for opportunities. The only way we can make sure it’s a safe discharge is to tap into as many resources as possible," says Caroline Keane, RN, MSN, ANP, CCM, director of case management and social work for New York Hospital, Queens. The hospital is a private nonprofit hospital in downtown Flushing. If the indigent are documented and don’t have behavioral issues, it’s fairly easy to place them in a skilled nursing facility (SNF), she says. "We get a lot of patients who are on Medicaid. They are indigent in the short run, but they are the bread and butter for some nursing homes."

When patients are just over the financial threshold for Medicaid, the social workers at the hospital can refer them to community groups who provide free medical care or long-term care facilities that will take the indigent.

Undocumented workers are a big problem for hospitals located in urban areas. St. Vincent’s Hospital in New York City has paid to transfer patients back to their home countries because they could not be safely discharged home and did not quality for post-acute services.

"If someone doesn’t have a green card, they can’t get continuum-of-care services. They can get urgent cardiac treatment or dialysis covered by Medicaid for brief periods, but if they cannot safely be discharge to home, it’s a big problem," says Kathleen Powers, LCSW, discharge planning specialist.

Emergency Medicaid covers hospital care for these patients in New York, but they have no benefits for home care or nursing home care, creating a dilemma for discharge planners.

St. Vincent’s paid $15,000 to send a young man back to China after he drank lye and ruined his esophagus and couldn’t function. No nursing home would take him, and his family was back in China. "Ultimately, it was cheaper to send him back than to keep him," Powers says.

It cost $22,000 to send another undocumented worker back to Russia. "Nobody is comfortable taking people who are undocumented. There are some loopholes and some negotiating; and sometimes, we can work it out with some of the nursing homes. Each case is individual," Keane adds.

For instance, undocumented patients may be eligible for some services if they have paid into the tax system. "Sometimes, we are looking for free service. Home care agencies have a certain amount of free care in their budget. If someone is undocumented and going home, we may be looking at free durable medical equipment and free transportation home," she says.

Sometimes, undocumented people who are injured in a car accident are covered by the state’s no-fault insurance. "Occasionally, we keep them here and do rehabilitation until it will be safe for them to go home. Sometimes, it’s our only option. We never drop the ball. We always continue looking for something," she says.

Homeless patients who are independent, can walk, and don’t need skilled services usually can be guided into the shelter system, Powers says. "We have to fax the agency information on the patients’ medical conditions and guarantee that they are not infectious and that they are independent enough to manage on their own, even if they’re in a wheelchair."

If patients need antibiotics and can’t get into the shelter system, they’re the hardest ones to get nursing homes to take. "We do what we can to get Medicaid in place while they are here. Sometimes, a SNF will take a chance and accept a patient for short-term antibiotics," she says.

The biggest challenge is elderly patients who lose the capacity to advocate for themselves and have to remain in the hospital for two months or more until a hearing in front of a judge who appoints a guardian.

"We do everything we can to avoid it. We try to find prior power of attorney. If there are no funds, we end up paying the cost of legal fees for the hearing; but while the patient is sitting here waiting for the court hearing or a place in a shelter, we do not get paid," Powers says.

The staff use their ingenuity to identify people who are mentally incapacitated and who come in as unknown. They may find the person’s address and use the Coles Directory (an Internet directory service — to find out who lives at that address.

"It’s a lot of detective work. We call anyone in the building who has a listed phone number, hoping we can locate someone in the building who knows the patient or the next of kin. We’ve been really lucky in locating people this way," she says.

By establishing close relationships with local long-term care facilities and leveraging the amount of business they give them, Keane’s department is able to place about 300 patients a month, some of whom have significant problems and little or no funding.

"When we give a nursing home a lot of business, they are usually willing to help us with the patients who are difficult. They know how much business we give them; and occasionally, they have to take a case that’s less than perfect," Keane explains.

If patients are indigent and have a family who will who will work with the Medicaid system, the hospital usually can place patients with Medicaid pending. "If we know the application is good, there are facilities that will look at the full picture with us and decide if they are willing to take the risk," she says.

If a patient is medically stable but disoriented and has no one to advocate for him or her, the hospital works with nursing homes to set up a guardianship. Occasionally, the hospital handles the guardianship alone.

"We get as many referrals to as many skilled nursing facilities as we can as quickly as we can. We know who may be hungry enough to spend money to get the long-term guardianship in place," she says.

The hospital has a contract with Curaspan, a Newton, MA, provider of connectivity and network management, for its eDicharge platform discharge planning solution.

The system allows the hospital to enter the patient information once into the eDicharge database, which searches for available facilities.

"The system allows us to write the story once. We don’t have to refax to everyone. We can widen the circle as we need to until we find a facility that will take the patient," Keane says. For instance, she was able to set up a SNF transfer for one patient without his ever being in her hospital.

The man was a New York City resident but was in Canada when he had a massive stroke. The wife came to Keane for help. "He was a laborer with no nursing home benefits, and he was on a respirator. We made referrals to about six facilities, using eDischarge and within four or five days, were able to airlift him from Montreal," she says.