Discharge planning helps patient independence

Part 1 of a 2-part series

The pressures being brought to bear by the imminent change to the prospective payment system (PPS) have home health agencies talking about discharge planning and its role in keeping visits down and costs under control.

For two Texas agencies, the emphasis is on early discharge planning — beginning at admission — to help patients understand their role in taking control of their conditions and becoming independent.

"At the beginning, from day one, we talk to them about the fact that we are going to admit you and help you manage your care with the goal that you’re going to be discharged and taking care of yourself," says Lucy Lee, RN, BA, MHA, CHCE, owner of Lee Health Care in Hamilton, TX.

"At the same time, knowing you can call us any time, even if you’re not our patient actively, we’ll still be there for you," says Lee, who is also president of the Texas Association for Home Care. "We give the reassurance that we’re not going to leave them high and dry, but we’re going to work with them toward their reaching a point of independence so they can be discharged."

Agencies also need to be very creative in helping patients piece together support systems of family, friends, and others to maintain that independence, says Emily Tripp, RN, MED, CHCE, group vice president for home care and hospice for the Visiting Nurse Association of Texas in Dallas.

It’s particularly important now, as the population ages, she says. "The average age of our patients is 85. If their children are 65, they may be very healthy and able to help. But we have a number of people who are in their 90s or 100 or more, and their children are in their 70s or sometimes 80s. They maybe are sick or becoming more frail themselves, and it’s not easy for them to take care of their family members."

Insight into PPS

The participation of Lee’s rural agency in a PPS demonstration project has given her insight into the effects of PPS on an agency’s resources. Her nurses have had to adjust accordingly.

Among the resulting improvements since the project began in 1996 — nurses are becoming more adept at quickly sizing up patients’ abilities to participate in their own care and enlisting them in the drive toward independence.

From the first contact, nurses are trying to determine who can help with the patient, and how well the patient can follow directions.

"That’s one of the things we look at on the first visit: What can the patient do for himself? What can he learn to do for himself?" Lee says.

She says that despite concerns about possible loss of assistance, patients can respond well to efforts at improving the efficiency of home care, if it’s put to them properly.

"While before, patients enjoyed being depen-dent, now we can speak positively of independence and they like it," Lee says. "And we have found that families and community people, neighbors, are more willing to help than we thought they were."

She says staff have responded, as well. "I have learned nurses can turn on a dime and they want to please and they want to do what’s right, so we gave it to them from that perspective. This is what we’re doing now and it’s going to be better for the patient when they are more independent and more involved in their own care."

Although there is not separate documentation directed at discharge planning, it is an element of the admission process. The goals for care include a plan for discharge within a certain length of time.

"We may not reach that goal, but then we’d set another goal that we would probably attain," Lee says. "And after a few months, we were much better able to see with accuracy when we thought we could discharge them."

Those forecasts, of course, vary radically depending on the type of patient being cared for:

• A patient being admitted while waiting to be transferred to a nursing home might require fairly intensive care for a brief period, from a few days up to a few weeks, Lee says.

In the meantime, the agency can provide personal care, nursing assessments for safety and sometimes needed therapy.

"It can be a pretty intensive plan of care, but the plan is always to discharge them to a nursing home when everything gets in order for that."

• For patients such as diabetics, who would be expecting to live at home indefinitely, it becomes necessary to assess their ability of self-care, including injecting themselves with insulin or using a glucometer.

"If it’s a person who is pretty lucid and able to learn, then we can anticipate we can keep them on for a couple of months, teach them about the disease and about the injection routine," she says. "If it’s more involved, at least we teach them to monitor their blood sugar, we give them the tools for recording and checking it."

• Patients with comorbidities, such as dementia or conditions affecting motor skills, have a much harder time learning self-care.

(Next month, Part 2: Social workers help find alternatives.)

Lucy Lee, Lee HealthCare Inc. 114 E. Main St., Hamilton, TX, 76531. Telephone: (254) 386-8971. Fax: (254) 386-5040. E-mail: llee@htcomp.net.

Emily Tripp, Group Vice President for Home Care and Hospice, Visiting Nurse Association of Texas, 1440 W. Mockingbird Lane, Suite 500, Dallas, TX 75247. Telephone: (214) 689-0077.