If discharge barriers arise, consider these solutions

Solutions range from commonsense to creative

A hospital's discharge process could be well-organized and include best practices. But what happens when patients are kept in an acute care bed, because the usual care transition options will not work?

A Stony Brook, NY, hospital has encountered this issue multiple times and has developed a variety of practices to resolve the problem. Here are some of the discharge solutions:

• Discharging patients who are undocumented immigrants. This is a problem that occurred often enough that the hospital's discharge team included it in the discharge barrier coding system.

"We developed a budget for patients to provide after care until they can get on their feet or until someone else can assist them," says Catherine Morris, RN, MS, CCM, CMAC, executive director of care management at Stony Brook (NY) University Medical Center.

The budget might pay to send the patient to a sub-acute facility in the patient's home country or to fly the patient's parent or other caregiver to Stony Brook, so the caregiver could assist the patient when discharged to the community.

"Some of these patients might have a payer source for while they're in the hospital, but no funds for care once they're discharged," Morris notes.

The hospital's social worker will help locate the patient's family members and assist with contacting them.

"We've tried to do some creative things," she says.

For instance, the hospital has been exploring the possibility of having an affiliation with local sub-acute facilities to rent or purchase beds for patients who need to be discharged to a lower level of care, but have funding problems, she says.

• Handling transitions when guardian issues arise. Another obstacle to a smooth care transition can be guardianship when patients are unable to make their own care decisions.

In New York, the attorney general's office makes decisions about guardianship of adults, and this can be a lengthy legal process, Morris notes.

Patients were holding up hospital beds, solely because the guardianship paperwork was held up in overcrowded court dockets.

"We've been working with the attorney general to move the guardianship papers forward," Morris says.

They found that one solution to the lengthy guardianship court process was to request a temporary guardian, who could participate in the patient's discharge planning and Medicaid application process.

"Now, we don't have to wait until the full guardian is appointed, which could take several months," she adds. "The patients would be in the hospital that whole time."

• Finding solutions to dialysis patient issues. The hospital's discharge coding system identified a barrier resulting from the lack of dialysis beds in the region. This problem means patients stay in the hospital longer than optimal, she says.

"The hospital is putting together a proposal to talk with the dialysis center to rent or purchase dialysis chairs," Morris says. "Depending on the final proposal, we'll either subsidize the treatment until the patient's insurance kicks in, or we'll look at doing a risk agreement with the dialysis center."

• Dealing with increases in uninsured patients. The economic downturn has increased the number of unemployed in the hospital's region, and the hospital has had increases in patients who arrive without insurance coverage, Morris notes.

"We have nowhere to place these patients, because other facilities won't take them," she explains. "And the Medicaid application process takes 45 day for approval, so we sometimes have to wait 45 days before discharging them."

Sometimes these patients could be discharged to a facility that would provide charity care, and sometimes the hospital discharge team could help them obtain home care services. Also, some patients qualified for the hospital's indigent funding. But as the problem grew, a bigger solution was needed, Morris says.

"We put together a medication assistance fund for patients who are uninsured or underinsured and who need only IV medications," she says. "We can work out something with the patient where the patient pays a part and we pay a part to provide them with the medications at home, so we can free up the bed and reduce our costs."

Another solution was for the hospital to work with the state department of social services to make sure Medicaid applications are going through in a timely manner, Morris says.

One solution was having a state Medicaid representative stationed in the hospital to help with Medicaid applications, she adds.

This has helped to speed up the application approval process, an outcome the discharge coding barrier system can track.

"There were many delays with Medicaid approvals," she says. "We keep track of any Medicaid application delays so we can give a report back about how their new program is affecting us."

The hospital hasn't rented beds yet, because the legal office still is exploring legal and regulatory issues, she adds.

Also, some patients who are waiting for Medicaid cannot afford their copayments when they are discharged to a lower level of care, so the hospital will share the cost with them, Morris says.

• Resolve care management issues. "Sometimes there's a care management delay, where the care managers didn't act as quickly as they could have," Morris says. "The physician or care team might be treating a patient whose case is medically futile, but the family demands aggressive treatment."

The patient might be in the intensive care unit (ICU), and indecision has kept the patient there for longer than necessary. If the physician refuses to stop the futile treatment, an ethical consultation will be called.

"We also work closely with our palliative care group and refer patients to them," Morris says.

There are other care management issues, as well.

"It might not be clear what the physician has in mind for the discharge plan, or maybe the discharge plan is not compatible or realistic, based on what services are available," Morris says. "If they say, 'I want the patient to go to sub-acute rehab,' but the patient doesn't meet the criteria for rehabilitation, then that's cause for delay."

The hospital's full-time physician advisor is involved with patient meetings where these care management issues are discussed.

"The physician advisor will review what is doable and what is not doable, and she'll go to the chief medical officer, if necessary," Morris says.

Also, the physician advisor will speak with the attending physician to make sure everyone is doing what's best for the patient and is being realistic about what can be done for the patient, she adds.