Discharge planners and home care staff need to improve communication

Problems may arise during transition

The transition from hospital to home health can be a rocky one, which is why hospital discharge planners need to make communication with home health staff a priority, experts say.

"Sometimes it doesn't seem as if anyone has been allowed the time needed to prepare for discharge," notes Lin J. Drury, PhD, RN, an associate professor in the Lienhard School of Nursing at Pace University in New York. Drury recently published a paper on what gets lost between the discharge plan and the real world when hospital patients are transferred to home care.1

"It seems the amount of time for preparing for discharges is decreasing," Drury says.

This has become a more urgent problem as increasing numbers of hospital patients need home health care after their discharge, according to data from the Agency for Healthcare Research and Quality (AHRQ).

AHRQ released a summary in October, 2008, showing how the rate of patients discharged from hospitals who still needed home health care increased 53% between 1997 and 2006. The same summary, which can be found at the web site, www.hcup-us.ahrq.gov/reports/factsandfigures/HAR_2006.pdf, noted a 30% increase in the rate of patients discharged to nursing homes or rehabilitation facilities during the same period.

Another new study shows that physicians are not referring high-risk patients to home care and other post-acute services as frequently as is needed.2

"I did an analysis of these patients to look at their medical characteristics and found that these people were pretty darn sick and had lots of needs, and yet they did not get post-acute referrals," says Kathryn Bowles, PhD, RN, FAAN, an associate professor at NewCourtland Center for Health and Transitions in Philadelphia.

In all, 56% of patients who had medical needs that experts agreed indicated a post-acute care referral did not receive one, Bowles adds.

From a home care professional's perspective, inefficient communication between the hospital and home care agency can be a problem, says Mary Kim, LMSW, a clinical liaison at Attentive-Primecare Home Health in Plano, TX.

"I used to be a social worker in the hospital and have knowledge of both sides," Kim says. "It's a disadvantage to patients and family if the home care agency does not lay their eyes on patients while they're still in the hospital."

Often, the communication between the two consists of the home care agency asking the hospital to fax over some information about the patient, Kim notes.

"But what you see on paper is not the same as actually seeing the patient," Kim says. "And that obviously can be a big barrier to the patient care."

Attentive-Primecare Home Health encourages hospitals to let Kim and other staff meet the patient to speak with him or her and evaluate the patient's needs, Kim says.

"We try to get an idea of what their expectations are and to see if there are any issues that need to be dealt with prior to the patient being discharged home," Kim says. "The only way we can do this is to literally lay our eyes on them and talk to them."

It's becoming increasingly rare for hospitals and home care agencies to communicate well during a patient's transition in care, Drury says.

"It seems that the number of clients each discharge planner has to handle is so much greater now that they don't have much time do anything more than say, 'Do you have a space for this guy or not?'" Drury explains.

Institutions need to recognize the importance of the discharge planner's role and give them enough time to do what they need to do to take care of people when they're discharged, because the alternative is to have patients who return to the hospital in a medical crisis, she says.

"Institutions are going to need to invest in allowing somebody to really do the discharge planning that's required," Drury says.

Since the typical hospital patient now is older and more frail than a decade ago, patients also are exceedingly ill at the point of discharge, Drury says.

"And the family is completely overwhelmed," she adds. "So unless the discharge planner has time to work with the family, all of the things listed on the discharge planning sheet do not have a chance of being followed."

For instance, during the stressful period of a patient being discharged from the hospital, it's often true that no one thinks about how the patient will obtain his or her medications, Drury says.

"They'll arrive home and realize they don't have any of their medicines," she explains. "Or they'll think they had a bottle of pills at home, but they're not what they thought they were, or they have the wrong dose."

Once upon a time, there might even have been a person connected with a health care system who would visit the client's home before discharge to see what it is like, but that role disappeared over 10 years ago, Drury says.

Instead, problems related to a patient's home environment are dealt with when they crop up as an emergency situation. For example, Drury knew a case where a patient was brought home on a stretcher and carried up three flights of stairs to his bedroom, but no one had considered that the house's only bathroom was on the second floor.

From the home care agency's perspective, staff often arrive at a new client's home only to find that the patient doesn't have the proper medication and equipment, Drury says.

"Or even if they have the right things in place, they don't know what to do with them," Drury says. "They thought they understood things before they left the hospital, but they're not able to implement the instructions."

Also, patients and their caregivers often assume that someone else is going to help them with immediate care, and no one is waiting for them when they arrive home, she adds.

"The home health aide won't be with them for a majority of the time they're home recovering, and for the rest of those hours, the family is completely stumped," Drury says. "Home care services are time-limited, and you must be demonstrating definite progress in order to continue to obtain that care."

This is a Catch-22, because the kinds of patients who typically receive home care services are chronically ill, and they often will get worse when they return home, she says.

"And there's not a lot of reimbursement that will allow for continuing care to somebody who is not going to get better," Drury explains. "Your typical Medicare reimbursement for home care after a hospital stay is very, very limited and very time-sensitive, so people often do not receive the full extent of services they would need to get better."

Not only do discharge planners need to work harder to anticipate problems and prevent them during the transition to home, they need to find home care agencies that are willing to go the extra mile.

Kim recently worked with an elderly woman and her caregiver daughter who were very anxious about being transitioned to home care because of the patient's history of having falls in the home.

"The daughter had been making many excuses to delay the discharge, so the hospital's social worker told me that this was a very difficult family," Kim recalls. "The social worker said they needed a home care agency that would connect with the patient and caregiver and take care of them."

Kim spoke with the daughter who had valid concerns about her mother's safety at home.

"We said we'd go to the home and do a safety evaluation, even though Medicare doesn't pay for those now," Kim says. "We had a physical therapist evaluate the patient at home, and we showed the family that they were going to be okay."

The home care staff outlined the steps the family had to take to ensure the patient's safety and agreed on a plan that made each person involved accountable, she adds.

"We would not have known the extent of the family's anxiety if the social worker hadn't given me a heads up about the patient's fears," Kim notes. "This is the collaboration that is needed between the hospital and the home care agency so that we can better serve patients and their families."


1. Drury LJ. J Contin Educ Nurs. 2008;39(5):198-199.


For more information, contact:

• Kathryn Bowles, PhD, RN, FAAN, Associate Professor, School of Nursing, University of Pennsylvania, 418 Curie Blvd., Philadelphia, PA 19104-4217. Telephone: (215) 898-0323. Email: bowles@nursing.upenn.edu.

• Lin J. Drury, PhD, RN, Associate Professor, Lienhard School of Nursing, Pace University, 41 Park Row, New York, NY 10038. Telephone: (914) 773-3557. Email: ldrury@pace.edu.

• Mary Kim, LMSW, Clinical Liaison, Attentive-Primecare Home Health, 3216 Tarrant Lane, Plano, TX 75025. Telephone: (214) 355-6223.