Patient perceptions guide discharge education process

Patients often want more than what's allowed

Transitions in health care are changing more quickly than patients' expectations, which is why it's important to address these expectations head-on, an expert notes.

"That's been one of our greatest challenges — setting appropriate expectations," says Pamela J. Tobichuk, RN, ONC, a nurse case manager with the pre-admission orthopaedic total joint program at Massachusetts General Hospital in Boston. Tobichuk spoke about using a pre-admission prediction tool to improve the discharge process at the 18th annual conference of the Case Management Society of America (CMSA), held June 17-20, 2008, in Orlando, FL.

Sometimes patients will have a long lag time between when they are first told they will need elective joint therapy and when they actually schedule such therapy, Tobichuk says.

"They've had all this time before the surgery to build up expectations," Tobichuk says. "They might have a preconceived notion about what it is they'll do, and way back when they first met with the physician this was not part of the conversation or focus."

Another reason expectations might be different is that patients often have a friend, spouse, or neighbor who has been through similar therapy, and the way this other person's discharge was handled was different, she adds.

For example, it's possible the patient's husband had knee surgery a few years ago, and the spouse was discharged to an acute rehabilitation facility.

Now, because of payer and Medicare changes, this option is unavailable to the wife, and yet she expected that's precisely where she would go after discharge.

"Most times we ask the patient, 'What is your plan?' and the patient might answer, 'Oh, I'm going to Spaulding Rehab,' which is an acute rehab facility," Tobichuk says.

So it's the discharge planner/case manager's job to educate the patient about which options are available.

"I educate patients on the levels of care, home care, and even outpatient therapy," Tobichuk says. "We teach patients that they'll have some sort of therapy or rehabilitation, but we better define how this will be done."

For instance, low-risk patients who are highly motivated might be sent home and referred directly to outpatient therapy, she explains.

Mid-level risk patients might be sent home to receive home care, including therapy in the home, and high-risk patients might be discharged to a skilled nursing facility, where they receive physical therapy.

Occasionally, a patient will insist that a referral be made to acute rehabilitation.

In answer the discharge planner can say, "Okay, I'll put the referral in, but I'm telling you this is unlikely," Tobichuk says.

The key is to engage the patient in the conversation, obtaining the patient's ownership of the discharge process.

Patients who feel that their opinions and concerns were heard and who are well-educated on what will happen to them post-discharge often report reduced anxiety about the discharge process.

"I try to explain that everyone's situation is different," Tobichuk says. "We look at every case independently, and we try to give them an opportunity to be proactive in their own discharge plan, to empower them to make some decisions about what they're going to need."