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Provide better ED discharge planning
Use resources to assess home environment
The health care system benefits when unnecessary hospital admissions are avoided, and sometimes the best place to impact that trend is by focusing discharge services on the hospital emergency department (ED), an expert says.
"If you can avoid an admission in the hospital, it's good for the patient, as well as for the health care system," says W. June Simmons, CEO of Partners in Care Foundation in San Fernando, CA. The nonprofit organization focuses on innovations in delivery-system design through early intervention and prevention.
One way it's good for the hospital is that many patients who use the emergency room for care are the same patients who lack adequate health care resources, as well as community support. So, they might become a compassionate care admission to the hospital, simply because hospital providers do not know where else to send them, Simmons notes.
"Hospital [providers] don't know what to do with these patients and will admit them to the hospital, even though they probably don't need an acute care level of care," Simmons says. "Admitting these patients to an acute care hospital is an expensive and sometimes a risky move for patients, because it's better for people to avoid hospitalization whenever they can."
What are needed are new models for ED discharge and hospital discharge planners who help providers improve these transitions.
"If a social worker could mobilize immediate private duty care in the home, then an ED patient could be discharged home," Simmons says. "Or the hospital social worker could help a patient transfer to a psychiatric unit or some other alternative site."
These types of ED discharge planning need to be explored, she adds.
Hospitals need to look more closely at an integration of community resources and mental health resources when working with care transition of ED patients, Simmons says.
"Some people say 80% of care for chronic conditions occurs in the home, so you have to mobilize the community," she explains. "Transitions are all about making sure someone who has a health challenge or frailty challenge remains at home safely and makes maximum use of the medical care offered to them."
This includes extending hospital/ED discharge planning to environmental assessments. For instance, someone should make certain patients have the necessary wheelchair ramps, elevated toilet seats, and other home adjustments needed to accommodate someone with limited mobility and chronic health issues.
Patients who are admitted to the hospital after an ED visit, or who are frequent fliers in the ED, often have home environment issues such as an untidy home, improper nutrition, floor tripping hazards, low lighting, substance use, or medication complications, Simmons says.
A hospital discharge planner should know of community resources that might assist with making a home environmental assessment or visit.
Other questions discharge planners should ask about patients are as follows:
- Does the patient have access to food and a safe environment in the home/community?
- Does the patient have transportation to community providers?
- Does the patient have access to medication and any necessary assistance with taking drugs?
This last issue is very important, because older ED patients discharged home often have multiple chronic conditions and a variety of medications to take. Plus, they might have several different doctors who each see only one part of patients' health picture and do not communicate with each other, Simmons says.
Another issue is whether the ED patient has Medicaid or some other payment system that will cover in-home care management.
"The Medicaid waiver is Medicaid with permission to provide ongoing care management in the home," Simmons explains. "You can buy things Medicaid usually doesn't cover like heavy-duty cleaning, putting in ramps and grab bars, and bringing in someone to give the patient a bath."
If patients can't find reimbursement for these services that might make it possible for them to stay at home, then they likely will be ED frequent fliers and end up hospitalized or transitioned to a nursing home for the long term, she adds.
"We've been looking at the Medicaid waiver program in California, and we've found that almost 50% have flagged up on electronic screening for medication alerts," she says. "These patients have signs and symptoms that might reflect a medication problem, including dizziness, confusion, and a history of recent falls."
Half of these patients had a combination of conditions and medications that would suggest the need for a pharmacist to review their medication history, and more than one-third of the patients had medical problems that needed to be brought to the attention of their doctor, Simmons says.
One of the most common problems is therapeutic duplication, in which patients are on three different medication prescriptions, and all of the drugs are in the same class, Simmons says.
"In the Medicaid waiver program, the care manager goes into the patient's home and does a complete assessment, looking at all medications," she adds.
"We developed an electronic system for screening for patients who have concerns, and then a pharmacist reviews these to see if there is a problem," Simmons explains. "So, medication reconciliation is a huge issue in discharge planning."
Discharge planning that spans the hospital continuum, including the ED, likely will be a more common practice as the Patient Protection and Affordable Care Act of 2010 results in philosophical and, eventually, payment shifts in the national health care industry, she predicts.
The Centers for Medicare & Medicaid Services (CMS) has already begun aligning incentives by announcing that it won't pay hospitals for readmissions within 30 days of certain medical conditions, Simmons notes.
Plus, health care reform bill's emphasis on prevention and evidence-based programs will drive a lot of the change.
"There is a whole lot of effort and resources being put into finding better ways of delivering care, and all of these efforts are promising to help us look for something that is more tailored to address where people fall out of the system and close these gaps," Simmons says.
If patients have medical crises, often the root cause of their emergency is related to inadequate discharge planning, she adds.
The goal is to provide rapid follow-up care when patients are transitioned from the ED or hospital to home and then to assess their situation and follow them closely, Simmons says.
"We need to put the resources in place to keep them stable at home and provide good continuity with their medical care," she adds.
[For more information, contact:
W. June Simmons, CEO, Partners in Care Foundation, 732 Mott St., Suite 150, San Fernando, CA 91340. Phone: (818) 837-3775, ext. 102. E-mail: firstname.lastname@example.org.]