Decrease readmissions with 'whole-family' approach

Consider needs of 'carers'

By Patrice Spath
Consultant, Health Care Quality
Brown-Spath & Associates
Forest Grove, OR

Figure 1. Career Assessment Questions

Unnecessary hospital readmissions can be avoided by a "whole-family" approach to discharge planning. Medicare requirements and The Joint Commission focus on evaluating and meeting the patient's needs, yet engagement and active participation of the family or lay caregivers also is central to improving the patient's transition from hospital to home. Case managers must work collaboratively with "carers" — those people who provide some form of care for the patient (i.e., family members, friends, or neighbors) — throughout all stages of discharge planning to ensure patients are adequately cared for after leaving the hospital. Informal carers and family members play a vital role in helping sick and disabled people of all ages maintain their independence in a home environment. To make this possible, the needs of these carers must be carefully considered during discharge planning.

Both patients and their carers should be involved in all stages of the discharge planning process and provided information on what to expect and their contribution to the process. Carers should be embraced as valued partners in the discharge process as their knowledge of the patient is vital in developing an appropriate discharge plan of care. Just as patients should have a choice about post-hospital plans, carers should be given a choice about their contribution. Otherwise, the inability or unwillingness of a family member or friend to provide care for the patient might not be evident until there is an unexpected readmission. Don't marginalize carers' concerns or patients may be sent home to unacceptable situations.

If the patient's admission is planned, provision of information to carers prior to the admission enables them to ask questions or raise concerns. Prior to admission or as soon as possible after admission, the patient should be consulted for permission to share information with the carer.

For patients admitted as an emergency, pre-admission planning obviously cannot take place. Under stressful circumstances such as an emergency admission, it is even more important to recognize the role of the carer from the start of the process in order to ensure that all the stages are well managed.

The admission process is the critical time to explain to carers what to expect and how they are to be involved in key decisions. Remember that they are the experts in what it is like to live with, or care for, someone with a particular condition or disability.

Case managers may find that patients and their carers have differing needs. For this reason, carers often require a separate assessment. There may be occasions where a carer's wishes conflict with the patient's desires. In these situations, case managers should review the patient's care plan and attempt to find realistic solutions for all concerned. Carers often will be willing to take on or continue caring for the patient if the case manager can arrange adequate physical and emotional support.

If a carer is being asked to make a life-changing decision (such as quitting a job or moving a family member into their home) the case manager can help by discussing various options. The personal health and social care needs of the carer must be considered as well as the role they are being asked to undertake. If these areas are not addressed, there is an increased likelihood the patient will receive less-than-adequate care after discharge. It's important to inform carers about support networks and community services that may be available to assist in meeting their physical and emotional needs. Particular attention should be directed to the individual's need for short-term breaks from caring. It is not only the time spent each week actually caring for the patient that has an impact on the individual. Just the ongoing responsibilities can create considerable anxiety from which the carer needs an occasional break.

To determine if relying on a layperson to care for the patient is a practical and sustainable solution, the case manager must assess the impact of the whole caring situation. Key questions to ask of carers are listed in Figure 1. During the assessment, listen carefully to what the carer is saying. The assessment is not a test. It provides an opportunity for the case manager to evaluate the patient's home situation and develop a plan specific to the needs of the carer as well as the patient. Great sensitivity may be required. It is important not to presume that the family member or friend wants to continue to provide care or should be expected to do so. Discussions about the patient's future can be difficult and carers often need a chance to talk through issues and consider their own needs. A holistic assessment of the whole situation — one that takes into account all parties' needs and aspirations — will lead to the best outcomes for everyone.

Family-centered case management is much more than just keeping patients and carers informed of discharge decisions. To ensure the patient's needs are met, carers must be confident of their ability to provide continued support and understand what is happening. This requires that carers be treated as active participants in the discharge planning process.