Look beyond the illness to create discharge plan

Take family dynamics into consideration

Case managers are more likely to develop a discharge plan that works if they look beyond the reason for hospitalization and take into consideration everything that has been going on in the patient's life, says Jackie Birmingham, RN, MSN, MS, vice president emeritus, clinical leadership at Curaspan Health Group, a Newton, MA, healthcare consulting firm.

In most cases, patient assessments are completed when the patient is admitted, and often information case managers need to develop a workable discharge plan is missing, she adds. "Case managers have so many responsibilities that they often don't have the time to get a good idea of the patient's living situation but they need to know about patients' home and family situation as well as their medical conditions," she says. When patients are admitted, they're very sick and may not give complete information. Case managers need to go back when they're more stable and start asking questions about their family and their living situation, she advises.

"There's no such thing as a complex patient. It's the complex family. Case managers need to know about family dynamics and the living situation," she says.

Find out how patients have been managing at home and get a baseline of their living situation before hospitalization. Ask how they get help with meals or activities of daily living, how they get to the doctor, and how their medical condition affects their life. Find out if patients live alone and if they have family to care for them. If they live on the second floor, find out how they were managing. "It doesn't have to be an inquisition. Just ask about their life situation and what it means to them as far as following a treatment plan is concerned," Birmingham says.

"It's almost become a cliché that discharge planning begins at admission, but many times case managers don't really follow through in terms of looking beyond the immediate, and taking what may happen in after a week or a month to bring patients back to the hospital," says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, consulting firm specializing in hospital case management.

Patients aren't always compelled to read their discharge paperwork and educational materials. When case managers go over the discharge information with patients, they should make sure the patients understand the message but go further and determine if they know how to incorporate it into their daily lives, she says. Take the time to determine what you can do to help patients follow their treatment plan.

"One of the best ways to prevent readmissions is through providing information to patients and families that they can understand and incorporate into their daily life," Kizziar says.

"We need to evaluate how useful the information we are providing will be to the patient and the family. It's one thing to say they need to do something, but we need to determine if what we are suggesting can fit into the patient's lifestyle and culture," she says.

Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm based in Los Angeles, adds that case managers need to form a partnership with patients and family members in order to have a successful discharge.

Find out how your patients make decisions. For instance, do they seek the advice of family members or friends? Listen carefully when they talk about their concerns about their condition and when they discuss their goals. "Sometimes the goals of the patient and family are not the same goals as the case manager or the healthcare team. In order to develop an effective discharge plan, case managers need to understand what the patient wants," she says.

When you are working with complex patients, it's important to facilitate a care conference and prepare the healthcare team for the conference, Miodonski says. "Often, multiple specialists are each telling the patient a piece of the treatment plan and discharge plan and nobody is putting the whole picture together. It's important to get the team together to review all the issues so everybody will have the same message," she adds.

During the conference, keep everybody focused on the target and continue to act as a patient advocate, she advises. Make sure that the treatment team presents options in terms that the patient can understand, she says. If the patient and family don't ask questions, ask on their behalf to help them get engaged.

Remember that unless patients have been declared incompetent, they have the right to self-determination. "Case managers need to keep in mind that while they want the best for the patient, they have to respect what the patient's wishes are," Miodonski says.

As patient advocate, the role of the case manager is to present all options and the consequences of each decision, she says. Help support patients and families in the decision-making process and try to understand why they choose the path they are taking, she says.

If patients are resisting a post-acute facility, it may help to have them talk with a representative from the facility. If families insist that they can care for the patient at home, get them involved in the patient's daily care, such as changing a bed with somebody lying in it. "Help them figure out what they have to do and when and they may see the enormity of care in the home," Miodonski says. Give patients and family members an alternative if the path they choose doesn't work.

When you talk to patients and family members, be sure to thoroughly document the conversation, Miodonski advises. "It's critical that case managers document their role in supporting the patient and family," she adds.