Critical Path Network

CMs, social workers collaborate on difficult cases

Nephrology unit poses discharge challenges

At Ingham Regional Medical Center in Lansing, MI, social workers and case managers work closely together to arrange post-discharge care of dialysis and ventilator patients on the nephrology unit.

"The patients on this floor have a lot of needs and a lot of issues. I work closely with the social workers to meet their needs. We have a lot of difficult cases and it's helpful for both of us to work together on them," says Carolyn Terry, RN, BSN, case manager for the unit.

Case managers are assigned by floors and social workers are assigned to multiple floors. The case managers handle discharge planning, utilization review, and communication with insurers. The social workers concentrate on psychosocial issues, transfers for substance abuse and psychiatric issues, and guardianships and durable powers of attorney.

When it comes to arranging a safe discharge for difficult-to-place patients, such as indigent or homeless patients or those who are on a ventilator and need inpatient dialysis, it may take both disciplines to ensure that the patients' discharge needs are met.

"I call on the social worker to help me find a discharge destination and set up community services for indigent patients and those who are homeless and to counsel with the families who are stressed over their loved one's illness," she says.

Terry typically manages the care of about 25 dialysis and ventilator patients each day.

The majority of her patients have end-stage renal disease, end-stage chronic obstructive pulmonary disease or lung cancer or amyotrophic lateral sclerosis. She and the social worker on her unit meet every morning to discuss every case and how to best meet each patient's discharge needs.

The entire case management and social work team meets every other week to brainstorm on difficult or interesting cases.

"As soon as patients are admitted, we start working on the discharge plan to make sure that everything is in place when they are ready to be discharged. We work as fast as we can but remain very conscientious about patient safety," Terry adds.

When new patients are admitted to her unit, Terry makes sure they meet inpatient criteria, calls the insurance company if necessary to get approval for treatment, and starts on the discharge plan.

"I have patients who need outpatient dialysis, some who need to be in a long-term ventilator unit, and others who need hospice care. I look at each individual patient to determine the safest and best discharge plan for them and their families," she says.

When a new patient comes onto the unit, Terry meets with the family and starts discussing the discharge plan. "A lot of cases can be difficult because the families want the patient to stay here because it's a safe place," she says.

Most of the patients are discharged to a post-acute facility rather than going home.

"If the family seems to be very emotional about the situation or resistant to discharging the patient, I call in the social worker who is skilled at working with people who are under stress. She helps get them moving along the path of discharge," she says.

Terry contacts post-acute facilities that might be able to take the patient, gathers the information the facilities need to make a decision, and faxes it to them. Meanwhile, the social worker is guiding the family as they choose a facility for their loved one. Terry recommends that families visit several post-acute facilities and choose which ones they like best.

She has made it a point to visit every facility in the area so she can be better informed when she talks to the families. "This way, I know what the place is like when I'm talking to the families about a placement," Terry says.

In some cases, patients on a ventilator can be discharged to home if their families can provide the needed care. The family must have two full-time caregivers who are committed to learning how to care for the patient.

If a family commits to caring for their loved one at home, Terry calls in the hospital's ventilator unit to conduct a home inspection and interview the family to determine if the family can safely handle the patient's care.

Families who are approved to care for the patient at home stay in the hospital, in the patient's room, for several days and receive training as they go about caring for the patient, much as they will do at home. Terry arranges for training from physical therapists, occupational therapists, respiratory therapists, and the outpatient ventilator company.

The social work/case management team's biggest challenge is placing patients who are on a ventilator and need dialysis and who must be transferred to a facility out of state because there are no long-term care facilities or nursing homes in Michigan that provide both services. The closest facility that takes ventilator and dialysis patients is in Illinois, which puts a huge burden on families who want to visit their loved ones, she adds.

"When I do have to place ventilator and dialysis patients in other states, the social worker spends a huge amount of time with them and their families, working to convince them that there is no other option," she says.

Terry and the social work team work together on finding a place for homeless patients to go after discharge. "They exhaust every possibility, calling family, friends, and neighbors. If there's no option, the social workers can get a voucher from the Red Cross to pay for housing for a few weeks or find a place at a shelter," she says.

Ventilator patients qualify for some type of insurance and can usually be placed in a ventilator unit.

"If they come in with no insurance, the social workers start on an emergency Medicaid application so they can go to a skilled facility as soon as they are ready for discharge," Terry says.