SW follows patients with discharge challenges
Early assessment identifies potential resources
When patients at Medical City Dallas Hospital are unfunded and have complex medical or psychosocial needs, the hospital assigns a dedicated social worker who follows the patient throughout the hospital stay from the intensive care unit to the step-down unit to the acute care floor.
The hospital uses a screening tool at admission to identify those who are at high risk, which may include patients who are uninsured, undocumented, or homeless. Those who are likely to have complex discharge needs are assigned a social worker who is experienced and familiar with community and other resources.
"The social workers who are assigned to the complex patients have the experience to know where to start to identify post-discharge resources for these patients. Some have expertise in certain areas, such as mental health or stroke. We have found that it makes all the difference," says Pat Wilson, RN, BSN, MBA, case management director at the 592-bed hospital.
The dedicated social workers still carry a caseload, but the hospital makes accommodations when they are handling complex cases.
Social workers typically spend more time with unfunded patients, in part to build trust. "We are asking for personal and financial information and we have to build trust with the patients to get what we need. We want patients to know that the social worker's role is not as an adversary but as someone who will help them and won't report them to immigration. We spend the time and effort it takes to make sure the patients know that we are their advocates," she says.
The social workers start with basic questions, such as whether patients have a Social Security number, if they are documented, and where their papers are. If the patient has a disability that meets the requirements, they help them apply for Social Security disability benefits. If they qualify for Medicaid, the social workers will help them apply and occasionally call a government official to push the application through.
"We explore every option with the patients and families and don't leave any stone unturned. Our philosophy is that we'd rather ask the questions and get all the information we can to ensure a successful discharge," she says.
The case managers and social workers at Medical City Dallas conduct a psychosocial assessment of patients along with their assessment of the clinical picture. "Often the psychosocial issues are as important if not more important than the medical issues in the discharge plan," she says.
For instance, if a patient who is being treated for pneumonia and needs oxygen is homeless, he's not going to be able to get oxygen on the street. In that case, the social workers and case managers work with the physician and develop a treatment plan to meet the end goal of a safe discharge. In some cases, the patient's length of stay may be extended while the respiratory therapist works aggressively to wean the patient from oxygen.
When patients are uninsured, staff assess their financial situation and determine what they can afford to pay toward their discharge needs. "Whenever possible, we try to get the physician to prescribe the medications that some retail pharmacies have on their $4 formulary. If not, we ask the family what they can afford to pay and we pick up the rest of the cost," she says.
However, the social work staff encourage patients and families to pay at least a fraction of the cost of the medications. "We want the family to pay a portion, even if it's just $1. If they have skin in the game, they're more likely to be compliant," she says.
The discharge planning staff have family conferences early in the stay and involve caregivers and family members in the discussions about what their post-acute responsibilities will be.
They educate the patients and families about the new healthcare exchange and help them get access. If patients live in Dallas County, the staff may refer them to the Dallas County Hospital, which has specialty clinics and outpatient services such as dialysis and chemotherapy as well as other county resources, such as clinics for low-income patients. "We use every resource available and make their first clinic appointment and get them into the system," she says.
When homeless patients require post-discharge care, the case managers attempt to discharge them to a shelter that provides medical care, Wilson says.
"But we can't make them accept the discharge plan. If they say they'll be safer on the street than in a shelter, we let them make the decision to go back to wherever they were living," she says.
When patients are discharged back to the streets, the social workers and case managers often need to provide support for the bedside nurses who are upset about the situation. "We try to help them understand that if someone has been homeless for 10 or 12 years, we can't change the situation in one hospital stay," she says.