Discharge Planning Quarterly

DP process begins five weeks before surgery

And ends after discharge

Discharge planning for orthopedic surgery patients at one major hospital begins well in advance of patients being admitted for surgery.

In fact, the discharge planning process begins about five weeks before the surgery, when the case management department sends patients a letter asking them to call a case manager for a 20-minute telephone interview, says Pamela J. Tobichuk, RN, ONC, a nurse case manager with the pre-admission orthopaedic total joint program at Massachusetts General Hospital in Boston.

"We have a list of upcoming surgeries through the scheduling operations," she says.

Tobichuk has found that it works better to ask patients to call them to schedule the initial telephone interview, rather than having case managers call them at home and catch them off guard or at a bad time, Tobichuk notes.

"I've tried calling patients to do the interview, and it didn't work," she adds.

With administrative support to pick up the voice mail messages from patients, Tobichuk has found the scheduled interviews to be an efficient use of her time.

"My hours are from 10 a.m. to 8:30 p.m., three nights a week," she says. "My hours are such that I can accommodate people, and I'm also talking to facilities and agencies throughout the day."

By scheduling the calls, patients and their families also benefit.

"I've found that patients will have their families over when I call, and they'll have me do a conference call to include the family in on the conversation," she adds.

This first telephone conversation is used to assess the patient's risk post-surgery and to work with the patient to come up with a plan for where the patient will be transitioned after surgery. They use a six-question, pre-admission prediction tool.

Then Tobichuk will ask about the patient's needs and thoughts and then review the patient's answers to the assessment questions.

"In addition, we're adding questions about their living situation and the layout of their home," she adds. "Then we come up with their score, and we talk about it and what it means in relation to what they want."

The patient will agree to a plan, and if Tobichuk agrees with it, they'll proceed in that direction.

Occasionally, a patient will insist on a plan that Tobichuk believes will not work, so she'll agree to keep that as Plan A, but also will develop a Plan B as a backup.

Tobichuk tells such a patient: "We know you want to go home after surgery, and you scored seven points on the risk tool, so we'll try to get you home, but if your body doesn't cooperate with it, you need a backup plan," Tobichuk says.

Once those telephone conversations and pre-admission assessments take place, Tobichuk can decide whether a patient needs more education, and she can assess the patient's needs for pharmacy information.

"And I make follow-up calls to the payer or insurance company," Tobichuk says.

Also, if the patient will be discharged to a skilled nursing facility, she will call the SNF and ask it to save a bed for the patient.

"No one will guarantee holding it, but this is a nice population with a quick turnaround, and they'll only be in the hospital for a few days after surgery," Tobichuk says. "So we can almost hold a place for them in a facility."