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DPs need to communicate with families about APS
Study finds APS used as "safety net"
Challenging times economically mean discharge planners might have fewer referral options than they've had in the past. This gap could lead discharge planners to find solutions that create other problems.
For instance, hospital discharge planners sometimes rely on adult protective services (APS) as a safety net for problematic cases at discharge when better family communication would be more appropriate, research shows.1
DPs sometimes call APS when there's evidence of abuse. But they'll also call APS when they're concerned about safety. For example, there might be a case where the patient needs either home care services or to be transferred to a nursing facility, but the patient and family, who often do not have health care coverage for home care services, insist they can handle everything on their own.
"Part of what happens is when there's any programming change for how hospitals or nursing homes or home health agencies are reimbursed for care, those policies inadvertently influence who you choose to take for a resident in your nursing home or for a client in your home care agency," says Lori L. Popejoy, PhD, APRN, GNS-BC, an assistant professor at the University of Missouri School of Nursing in Columbia, MO.
So, the discharge planner's options for referral are limited, especially if the patient doesn't want to pay for out-of-pocket support services.
And the DP is worried about sending the patient home without any additional support. Since the state pays for visits and services provided through the adult protective services office, the DP will call APS about the patient, Popejoy says.
"They hope APS will be able to convince the family to take additional services," Popejoy explains.
Plus, by calling APS, the discharge planner feels as though she at least did something to help the patient. But this approach isn't optimal, Popejoy says.
"APS should be there and really used in places where adults need protection," Popejoy says. "But because of dramatic service cuts to Medicaid in our state [Missouri], they're calling adult protective services to get services to people."
The problem is that DPs in Popejoy's study were not communicating their plans to patients and families, and this raised ethical concerns, Popejoy says.
"Discharge planners were inclined to call adult protective services to say, 'This person is going home, and we're very concerned about him,' but there was a tendency to not tell the older adult that they had been hot-lined to adult protective services," Popejoy explains. "That's a little bit of an ethical problem."
The patients in these cases were older, frail adults who are returning home with older, frail spouses. And there is concern that they might not be able to handle the medication and other health care issues, she adds.
Discharge planners would recommend a discharge plan that helps the patient, but the patient and family might decline.
"You can encourage them and tell them about services available to them, but you can't force them to do something they don't want to do," Popejoy says.
The ethical dilemma is when DPs call APS to say that they have an older patient who is returning to a potentially unsafe home environment, but they do not tell the patient and family that they've done so, she adds.
"My concern is that when health care teams don't tell them they'll call APS, then they're potentially missing a really good opportunity to talk with the patient about it," Popejoy says. "They could tell the patient, 'I'm very concerned about your going home; I don't think you'll be safe, so I'm going to call adult protective services to tell them I'm concerned about your going home.'"
Another approach would be for DPs to hold a patient/family meeting and explain the exact nature of the health care team's concerns, Popejoy suggests.
The DP could explain why the health care team is concerned and discuss the issues the patient and family are facing, she adds.
"Have a forthright conversation with them, asking them, 'How do we get you to the next level of going home?'" Popejoy says.
"I honestly think that calling APS is not completely realistic, but if we're taking that approach, we need to be clear with patients and families, because you could fracture your trust with the patient," she adds.
"Tell them that you have concerns, and you feel they need more services than you're able to give them, so here's a phone call you can make," Popejoy says. "Tell them that a case worker from APS will call them to talk further and you really hope they'll take the time to talk with them and hear what they have to say."
1. Popejoy LL. Adult protective services use for older adults at the time of hospital discharge. J Nurs Scholarsh. 2008;40(4):326-332.
For more information, contact:
Lori L. Popejoy, PhD, APRN, GNS-BC, Assistant Professor, University of Missouri, S320 Sinclair School of Nursing, Columbia, MO 65211. Telephone: (573) 884-9538.