Developing a successful discharge plan for patients with a history of drug abuse takes creativity, patience, and flexibility, says Maria Seavey, RN, BSN, CCRN, case manager in Massachusetts General Hospital’s cardiac medical-surgical care unit.

Take the case of a 40-year-old woman from New Hampshire. She was transferred to Massachusetts General from a New Hampshire hospital after she suffered a cerebral aneurysm rupture following a possible heroin overdose. After recovery, physicians discovered vegetation in the patient’s aortic valve. She underwent an aortic valve replacement, spent four weeks in ICU, and developed methicillin-resistant Staphylococcus aureus (MRSA), which required six weeks of IV antibiotics.

When Seavey met the patient on the cardiac surgical step-down unit, she still was severely deconditioned and required a tracheostomy, a gastrostomy tube, peripherally inserted central catheter, a Foley catheter, and needed telemetry.

“My original plan was the suggestion that she be transferred to an LTAC [long-term acute care] facility near her home, but there are no LTACs in New Hampshire,” Seavey says. The patient did not have health insurance.

This meant the patient had to stay at Massachusetts General and receive therapy until she was stable enough to be transferred to a skilled nursing facility near her home. “The physical therapists, occupational therapists, and speech therapists worked with her diligently, and the nurse walked her three times a day,” Seavey says.

When the patient was almost ready to be discharged to the skilled nursing facility to complete her rehabilitation, she was started on methadone at a time when Seavey was not at the hospital and couldn’t give input to the prescribing physician.

Physicians in New Hampshire skilled nursing facilities do not have the authorization to prescribe narcotics for withdrawal. This meant the patient would not be eligible for a skilled nursing stay, and Seavey had to come up with a third discharge plan.

Ultimately, the patient was discharged to her parent’s home with orders for a visiting nurse and a daily appointment at a methadone clinic.

“Financially, this was expensive but it was the safest discharge plan,” Seavey says.