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Identifying sources of support for families
Families increasingly are bottom line
One of the chief issues as hospitals continue the trend of transitioning more patient care to subacute or community/home settings is the availability of financial and service resources.
In some areas, including rural regions, this can make discharge planning much more complex.
"The challenge is that we have had a slow eradication of personal care in this country," says Lori L. Popejoy, PhD, APRN, GNS-BC, John A. Harford Foundation Fellow and assistant professor in the Sinclair School of Nursing at the University of Missouri in Columbia.
"You can pay for it privately, or your family can do it for you, or you might be Medicaid eligible and receive some personal care services," Popejoy says.
But Medicare provides far less personal care support than it once did.
"Medicare visits are shorter with home care and not as generous as they used to be," Popejoy says. "So who picks up the slack? It's the family and it's the spouse."
This is why the discharge team should identify other sources of support for the family when an elderly patient desires to return home and this poses a health risk. The hospital team can do this by making repeated visits to the patient while the patient is hospitalized and learning the family situation. If the family is amenable to home care visits and these visits can be financed, then the discharge team should communicate the family's history to the home care agency, so they'll also be aware of the risk, she adds.
"Ten years ago we'd have home- and community-based services for people who are nursing home- or Medicaid-eligible and these services would keep them out of the nursing home," Popejoy says. "The services would include personal care shopping, yard care, and transportation to doctor's appointments."
Now such concierge services are not available except to those with the best health care or financial resources.
"The barriers to keeping people out of the hospital are pretty extraordinary for some cases," Popejoy says.
So hospital discharge teams need to assess a patient's personal resources, including family members or neighbors who would be willing to take him or her to follow-up doctor visits and take care of other household chores.
When it's clear these community-based resources are inadequate, the team should discuss the issue with patients and their family members, asking if there are any additional personal resources the patient might have.
In some cases the resources are less than ideal, but if the patient desires them, this should be the goal. For instance, the patient might be living with an unemployed child who is financially dependent on the parent, but does provide some support for household tasks and personal care.
"Yes, they're living off mom's Social Security check, but they're taking care of her, and she is well cared for and clean," Popejoy says. "People might find themselves in that situation unexpectedly."
These situations will become more common as increasing numbers of Americans pass age 60 and their health declines. Plus the trend of dwindling community and national support services will continue, Popejoy predicts.
"We're faced with pretty huge challenges in the next decade," she says.
"The population is getting old pretty fast, and they'll use more hospital days," she adds. "All of this is happening in the face of a declining health care workforce."
Patients who lack community resources are discharged home. Soon they are readmitted to the hospital, a cycle that continues when there are no interventions to find alternative transitional care options.
"I see it as a perfect storm on the horizon," Popejoy says. "We have an increasing population of older adults; some live with their children; some are on their own; some live with spouses."
It's the hospital discharge team's job to help their transition be one that is not just physically moving them from the hospital to a new place, but also one that helps patients continue to improve their health and mobility.
Family dynamics should be a chief focus of transitional care teams as the nation's health care focus increasingly places more responsibilities on the family, Popejoy notes.
"Ninety-five percent of people live in the community, and for the most part we handle this successfully," she says.
"Also, most of the personal care and post-hospital health care is delivered by family members, so the patient's family is the backbone of our system," she adds. "From a discharge planner's perspective, the family is your strength, and they're the ones who will keep things going."