Every case management leader should be educating their teams on how to deal with complex and difficult-to-discharge patients so the case managers will know what to do when they face a specific issue, says Carolyn Hamilton, MS, RN-BC, CDDS, CPHQ, corporate director of care coordination for DCH Health System.

Hamilton has developed an educational presentation for her case management team on how to deal with challenging cases so that upper-level staff don’t have to intervene in every case.

The following are some of her tips on working with difficult discharge cases:

• Patients with a criminal history. In the hospital setting, staff members do not need to know patients’ criminal history in order to treat them, but referring facilities often have policies about accepting patients with a history of certain offenses, Hamilton says. It’s the responsibility of the receiving facility to ascertain patients’ criminal histories, Hamilton says.

“If case managers learn about a patient’s criminal history, it’s usually hearsay and we encourage not passing the information on. We share only information related to patients’ medical care with post-acute providers. If a facility has a policy in which it does not accept patients with certain criminal histories, it is up to that facility to check the state and federal registries prior to accepting a patient,” she says.

In some cases, the hospital has involved the patient’s parole officer in the discharge planning process with the patient’s consent, Hamilton says. However, she adds, many of the patients are elderly and the offense was so long ago that they no longer have a parole officer.

“We keep enlarging the referral net across state lines until we find a place for the patient to go,” she says.

Sex offenders are the hardest to place, Hamilton says. Sex offender cases can be disturbing to team members, Hamilton points out. “But it’s important that as professionals we remain nonjudgmental and keep our objectivity. When patients don’t qualify for acute care treatment, they can’t stay in an acute care setting,” she says.

• Patients who refuse to leave. When patients want to stay after discharge is ordered, it’s a challenge for the entire hospital staff, Hamilton says.

“There are a lot of reasons patients refuse to leave and it’s often difficult to learn what they are. Determining their motives is the first step in expediting the discharge,” Hamilton says.

In some cases, patients and family members refuse to leave because the only facility that can provide the post-acute services the patient needs is in another city or even another state, Hamilton says.

But this doesn’t mean the patient can stay until a bed opens up in a closer facility, she adds.

“Patients cannot stay in the acute care hospital for convenience. We are bound by the Medicare Conditions of Participation that require us to develop a safe discharge plan when the patient no longer meets medical necessity,” she says.

Hamilton points out that federal law does not mandate that patients make a choice of a post-acute provider. The law says that hospitals must offer a choice. “If they refuse to make a choice, we blanket the area with referrals to find a facility that might be able to meet the patient’s needs,” she says.

Case managers must always make sure there is a safe discharge plan in place and documented in the medical record and that patients no longer meet medical necessity criteria.

If Medicare patients appeal their discharge to their Quality Improvement Organization (QIO) and the QIO rules in favor of the hospital, the case manager gives them a Hospital Issued Notice of Non-coverage 12 (HINN 12) and a bill for the cost for a night’s stay.

In the rare cases when patients continue to refuse to leave, the case managers alert Hamilton, who assists in escalating the case.

“The ultimate decision to have a patient who has been discharged removed when he or she no longer meets medical necessity must ultimately be made by the chief executive officer in my facilities. Usually, we can have security go with me to talk to the patient and family, and they’ll agree to the discharge. But in a few cases, we have to escalate it further,” she says.

The hospital legal team also should be consulted, Hamilton says. However, she points out, attorneys can’t rule that patients are ready to be discharged. Only a physician licensed to practice medicine can determine that a patient no longer meets medical necessity criteria, she says.

“Case managers should remain apart from the efforts to remove a patient and stay in the role of patient advocate to ensure that the discharge plan is safe,” she says.

• Unfunded or underfunded patients. If patients do not have insurance, case managers must look at every available option, Hamilton says. Learn to differentiate between real and perceived barriers, she adds.

For instance, if the patients are eligible for Medicaid, help them apply and look for a facility that will accept patients with Medicaid pending.

If patients have recently left a job, they may be eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA) insurance, which allows them to continue their former employer’s group insurance for a period of time, usually up to 18 months. DCH Health System sometimes will assist patients by funding COBRA payments for a few months in order to get them to the right level of care.

A 70-year-old woman may not have Medicare because she never worked, but she could qualify for spousal benefits. “Is there a free care plan? Are they eligible for Medicare? Are they eligible for a Veterans Administration benefit? It takes tenacity and assertiveness to help patients navigate the healthcare maze,” Hamilton says.

“We have to be willing to look outside the box for solutions,” she adds.

A patient who was hospitalized out of state due to an injury may want to receive post-acute care in his or her home city. The patient might have a life insurance policy with a cash value or a retirement fund that could be used to fly him or her home, Hamilton says. Sometimes, family members may come together to assist with this expense if it’s not covered by the patient’s insurance, she adds.

“At the end of the day, it’s all about doing the right thing for the patient. Patients can’t live in the acute care hospital and it’s up to us to ensure a safe discharge plan is in place and successfully discharge the patient to the next level of care,” she says.