Critical Path Network

Self-determination form documents patient choices

Form includes information in triplicate

When patients leave St. Vincent’s Medical Center in Jacksonville, FL, with referrals for post-discharge services, they take home a copy of the hospital’s self-determination referral form, with information details about which providers they chose on the front and the list from which they made their choices on the back.

Another copy goes into the patient’s medical record, and the third copy is retained by the case management department.

"It’s basically simple. The social worker or case manager can talk to the patient and show them the back of the form. The patient makes a decision, and it’s documented," says Jamie Zachary, LCSW, the hospital’s director of care management.

The hospital goes beyond the Centers for Medicare & Medicaid Services requirements for giving patients post-discharge choices and gives all patients a choice about home health services, durable medical equipment companies, skilled nursing facilities, and ambulance companies.

The hospital’s self-determination referral form is printed in triplicate. The front of the form, filled out by the care manager or social worker, identifies the resources to which the hospital made referrals and includes a statement at the bottom that the patient was given the list and given a choice.

The form is signed by the patient and by the staff member. The back of the form contains a list of all providers who requested to be on the list and identifies those that are Medicare certified with asterisks and those in which the hospital has a financial interest in boldface type. (See form)

"Patients find it helpful to have this information when they get home, particularly if the durable medical equipment company or home health agency doesn’t show up as expected. They have the name and telephone number of the provider handy and don’t have to call the hospital for help," Zachary explains.

As soon they know a patient will need post- discharge services, the care manager or social worker presents him or her with the list of providers. In the case of patients who can’t decide on a facility or who don’t want to choose, the staff rotate through the agencies on the list.

The discharge planning staff are familiar with the companies and what services they provide and work with the patient to help them choose.

"Giving an elderly patient a list of 30 companies is daunting to that patient," Zachary adds. "If the patient needs a particular service and we know only four companies provide it, the staff points out these four and helps the patient narrow it down."

The hospital notifies patients as to which agencies are preferred providers for their health plan, and, in most cases, that is the provider the patient will choose. When physicians write an order for a specific company, the care manager or social worker explains that the patient has the option of considering other providers. Most patients go with the physician’s choice, but the hospital has documented that they know they have an option, she points out.

The hospital encourages family members to check out skilled nursing facilities as early as possible, dropping in on the facility, talking with the administration, and taking a tour.

Whenever possible, the care managers and social workers ask patients and family members to select more than one facility and to authorize that patients’ personal identifiable medical information be sent to several facilities to ensure the hospital can find an available bed.

"A lot of times, the family will consider only skilled nursing facilities within a few miles of their home. That narrows it down. We tell them which ones they are and encourage them to visit," she says.

The hospital has a significant number of patients who do not live in the greater Jacksonville area, many of whom are cardiac patients from South Georgia.

The list includes a statement that says that resources out of the area are available. The cardiac care management staff has a list of facilities and agencies in South Georgia and provides that list to patients from that area.