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Finding discharge options for uninsured immigrants
Paying for a lower level of care an option
"When faced with an increasing number of immigrants who don't have funding for post-acute care, hospital case managers and social workers must use their ingenuity to come up with creative options that lessen the financial burden of care," says Deborah Cruze, JD, MA, program associate, health sciences and ethics at Emory University's Center for Ethics in Atlanta.
If patients have someone to care for them in their native land, it may be a good option for hospitals to pay for an air ambulance to return them home, Cruze points out.
"The dilemma arises when patients are not going to be able to receive anything close to the kind of care they need in their home country," she adds.
In those cases, look for less expensive ways to provide care for patients in a less acute setting, Cruze suggests.
For instance, when Cruze was a clinical ethicist at Grady Memorial Hospital in Atlanta, the hospital looked at the feasibility of renting an apartment for patients to live in while they received outpatient care, depending on how complex their clinical needs were.
"In some cases, it was a cost-effective option to bring family members here to take care of them for a certain length of time," she says.
When the staff at WellStar Kennestone Hospital identify undocumented immigrants who are likely to have post-discharge needs, the care coordinators meet with them and talk about what kind of options may or may not be available to them, says Regina Hasan, LMSW, executive director of social services for the WellStar Health System.
"If they will be able to go back to the community, the staff identify clinics or other services that can meet their needs. If they need long-term care, like vent-dependent patients, or those who have end-stage renal disease, we have to work on alternatives. We meet with the family and let them know that if the patients are in need of long-term care like skilled nursing or long-term chronic care, there are no options available in this country at this point, unless they are willing to pay for them," Hasan says.
At Medical City Dallas Hospital, case managers and social workers work as a team to look at potential options for discharging undocumented patients who have serious injuries or illnesses, says Pat Wilson, RN, BSN, MBA, director of case management at the 598-bed hospital.
"We try to understand the realistic outcome for the patient and that may be that the patient is never able to care for himself. We get the family involved immediately and talk to them about the likelihood of the patient recovering, what it means, and what kind of care he will need," she says.
Knowing realistic outcome
The physicians, case managers, social workers, physical therapists, occupational therapists, and others on the treatment team frequently meet to make sure that they all have an understanding of the goal of treatment and the patient's realistic outcome.
The case managers and social workers find out what kind of resources the family has, if they have someone who can stay home with the patient, and look at all the possibilities for post-acute care.
"If a patient is unfunded, the likelihood that he or she can get into charity rehab is slim. In those cases, we provide as much of a rehab program as we can to get those patients to the best level of functionality we can," Wilson says.
This means patients stay in acute care and have physical therapy, occupational therapy, and/or speech therapy several times a day — whatever will have the biggest impact to get the patient further along the road to recovery without being in the rehab setting, she adds.
"We tell the family member up front that the patient ultimately is their responsibility. We get them involved in the beginning and make them part of the team. That way, they know the expectation," Wilson says.
When the family is willing to care for the patient at home, the case managers usually can partner with a home care agency to provide two or three visits to help the family adjust at home.
Many undocumented Hispanic patients, particularly those who immigrated many years ago, do not have a family in the traditional sense but do have strong bonds in the community, Wilson says.
"Members in the Hispanic community tend to cherish and protect each other and are willing to do what they can. Sometimes, they want to do more than we think is in the patient's best interest and, in those cases, we try for charity rehabilitation or home health," she says.
"We give all our patients the facts and information about their condition, and if they choose to go home, we send them home," she says.
When a patient has a catastrophic illness or injury and doesn't have a family member who can be a decision maker, the case managers get the hospital's ethics committee to review the case.
Grady has made arrangements to pay post-acute providers to care for patients a certain length of time and agreed to take them back if they don't progress, Cruze says.
"These agreements tend to be difficult for the hospitals because the patients often return to acute care. It is a temporary solution that lessened the cost, but ultimately the hospital didn't become absolved of responsibility for the patient," she says.
Dialysis patients with no funding present a special dilemma for hospitals because they are usually stable enough to be discharged to the community, but they don't receive the regular dialysis they need because no dialysis center will take them if they don't have a payer source, Wilson points out.
"Dialysis patients must be aware that when they miss treatments, they are going to get worse and end up in the emergency room. We talk to them about how treating them only in the crisis mode is not the best kind of treatment and isn't a long-term plan," she says.
WellStar Cobb Hospital has kept patients with end-stage renal disease and no funding in the hospital for dialysis, but some have gotten tired of staying in the hospital and left against medical advice, Hasan says.
"Then their condition would get worse, and they would bounce back to the emergency department, often ending up in the intensive care unit, depending on how long they went without dialysis. The hospital was like a revolving door for them," she says.
At Medical City Dallas, the case management staff treat patients without funding "the same way they treat noncompliant patients and educate them that not being on routine dialysis schedule will shorten their life," Wilson says.
In instances when the patient has family in Mexico, the hospital's social workers bring up the subject of going back to Mexico for treatment.
"We have sent patients back to Mexico when they are stable enough to make the trip and we have 100% family support. They are grateful to go home to their loved ones to die or receive medical care," Wilson says.
The key to success in finding post-acute accommodations for unfunded patients is to take a proactive approach to discharge and involve the family members up front, keeping them informed on the goals of treatment and the realistic expectation for the patient's recovery.
"When we know what we think the patient's outcome will be, it gives us a place to start working with the family and looking at what resources they have and what we call pull together. If we wait until the last minute, the plan would never come together," she says.