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How to prevent crises during transitions in care
Woman lost leg in one tragic case
Discharge planners can prevent many problems that might occur during a patient's transition from the hospital to home care by focusing on communication with staff from the home care agency or other post-acute setting.
Experts suggest following these strategies:
Think about what communication needs to happen: Discharge planners should think about discussions they'll need to have with home health staff and, in the case of patients who are doing very poorly, discussions with payers, says Lin J. Drury, PhD, RN, an associate professor in the Lienhard School of Nursing at Pace University in New York.
"You may need to get in touch with social service staff right away, or you may need to convince Medicare or the managed care organization that quickly discharging the patient is not in the patient's best interest," Drury suggests.
Hospital discharge planners and home care social workers also need to communicate during and after the patient's discharge from the hospital to make sure the transition is smooth.
"There needs to be a follow-up from the hospital, with someone asking if the home care person made it to the home and if the patient is okay," Drury says.
Once a discharge planner has said good-bye to a patient, there needs to be someone on the other side who is making sure everything is working well at home, she adds.
Find out what the patient's home environment is like. After home health eligibility is determined, the discharge planner should ask the patient about his or her home environment to find out if it's handicapped accessible and whether there is adequate electrical supply for any home health equipment.1
Educate the patient about payer-imposed limitations on services. "We need to educate the patient regarding insurance and find out what other resources the patient has," says Mary Kim, LMSW, a clinical liaison at Attentive-Primecare Home Health in Plano, TX.
"Medicare guidelines have changed, and there are many limitations to what services can be provided," Kim says. "So you have to have a conversation with the patient to help them understand what the situation will be like at home, the limitations and barriers."
The hospital's social worker or case manager should discuss this first, and then it's time to get the social worker from the home care agency to talk with the patient, as well, Kim adds.
"There might be community resources that will work in conjunction with home care to provide transportation and other things," she explains. "The patient might need to hire a private duty sitter for the transition and have all of that in place before going home."
These sorts of decisions could be discussed by the hospital social worker and home care social worker before the patient is discharged, Kim adds.
Anticipate and prevent adherence problems. Discharge planners also need to clarify when and how patients will fill prescriptions and obtain medical supplies after discharge.1
And all discharge instructions need to be explained and demonstrated whenever possible.1
Teaching patients about discharge plans should be done thoroughly by the hospital discharge planner and then reinforced by home health staff, Kim says.
"We need to educate and constantly reinforce that to not only the patient, but also to the caretaker, spouse, and mother," Kim says. "Hospital social workers and case managers are very good at doing that, but the reality is there's absolutely no way a person will 100% understand the transition until it happens."
So it's important for the hospital to have the home care agency's social worker talk with the patient to provide information about community resources that could work in conjunction with the home care services, Kim suggests.
For instance, the person might need transportation to doctor visits or might benefit from having a private duty aide help with the transition home, she says.
"Also, if a patient is very anxious about returning home, then some home care agencies can do a same-day [as discharge] visit, even though Medicare won't reimburse for that," Kim says. "But we're doing it for the patient's safety."
A home visit also reassures patients that they will be fine once transitioned home, Kim says.
Some patients will become so anxious after being brought home that their health will worsen, and they'll return quickly to the emergency room, she adds.
Sometimes, there are even worse outcomes.
Drury recalls a worst case scenario in which a patient nearly died during a transition gap in care.
"I've done some consulting on medical malpractice cases involving home care agencies," Drury says. "One of the horror stories involved a younger woman who had been in a serious auto accident and was discharged in traction at home."
The woman's only caregiver was her elderly mother, although she had been transferred to a home care agency.
"In the three days between when she arrived home and the home care agency arriving to visit her, the patient developed blood clots because her mother couldn't handle her in traction," Drury explains. "She ended up losing her leg that was in traction."
When the lawsuit was settled, the hospital took responsibility for discharging the patient before the patient and caregiver were ready, and the home health agency took responsibility for not getting to the home fast enough, Drury notes.
"The client got a settlement, but she still didn't have the leg, and her mother continued to feel horrible for the rest of her life," she adds.
Discharge planners need to watch for patients who might need more services and faster services, so these can be discussed with the home health agency to make the transition smoother.
1. Drury LJ. J Contin Educ Nurs. 2008;39(5):198-199.