Managing Patients on the Outside of Hospitals

[goodadvocate]

Although accountable care organizations have appeared I still feel there is little management of patients when they are discharged. The concept was to have this umbrella over coordinating care for patients at discharge to keep them from being readmitted but there just isn't enough.

Enough of what? Enough nurses, enough information, enough collaboration, enough management, enough questions, enough accountability!!

Enough nurses that are within the organization to educate and coordinate care among the patients who leave. We're still giving them a document that we're not sure they understand and telling them what to do.

Enough information to know what home is. Do they have a safety net at home? Who lives with them? I once had a patient being discharged out of the hospital after a TIA. No one asked him what home was. The boxes were checked for him to be stable enough to go home. BUT now he couldn't drive. It turns out that he was the caregiver of his wife who had dementia, and he did the shopping and the cooking and the driving. He would be leaving without being able to drive for 6 weeks.

Enough collaboration to know who can work with those being discharged and what appointments do they need. The hospitals tend to be the "fortress" wanting to manage everything under one roof thinking that makes it easier. Accountability is an issue and I find it kind of funny that we had developed "Accountable Care Organizations" in a system that should have been accountable all along.

Enough Management, meaning to manage the needs of the patient and families. People are living longer, more family live apart and have their elderly parents living alone with an occasional phone call. If we don't manage those patients effectively they will return back to the hospital. Knowing what doctors they see, knowing what medication is they take, knowing they have monies for their medications and knowing they have transportation to their appointments. Managing patients is an important part of the accountability of the system. Physician offices that are seeing 28-30 patients a day don't have the staff or the time or the knowledge to know anything about managing their patients outside the 5-10 minute appointment they have with their patient.

Enough Questions,we need to start asking the questions. We need to know the patient, their resources, their community, their support system, their culture, their anxiety, their problems. If we don't ask the question they will return to what they feel is their safe zone. We as a system need to support their discharge with all the ducks in a row for them and then!!!

Enough Accountability, there is never enough accountability if there is any at all. When a problem occurs we used to go up the chain to lodge a complaint or tell the story. Hoping that those administrators, managers, executives, leaders would help make a change. What we found was the typical response from healthcare. They would listen, sometimes like they actually cared or get annoyed because how dare we bring them yet another problem that seems insurmountable to resolve and then we we returned to that same entity.....voila our challenges to get things done have become more difficult than it ever was before. So now we leave it alone and change the problem one client at a time as we are never going to be able to change the culture or the system alone.

So as you go forward in your practice, whether a staff nurse, a case manager, a discharge planner a social worker please remember there is never enough and make sure you provide enough for your patient before they go home.

[WC Case manager]

Well put!

[d'cm]

Elderly man calls 911 for food, dispatcher answers plea

I thought of this post as soon as I read this story. Check it out.

[Feliciaccm]

As a hospital Case Manager, I can assure you ... change is a coming. With CMS penalties, and insurance companies to follow the trend, for 30 day readmissions. We are tasked with reducing readmissions. The only way to accomplish this is to ensure our patients are well educated & have the resources to manage their health effectively.

The days of simply discharging to home with HHC or to a SNF are over. We are asking the questions & critically thinking to resolve issues that are uncovered.

[silverbat]

Also, no matter what services we offer, it is up to the patient to take part in them or not. Sometimes all the teaching in the worls and all the support in the world isn't going to convince the 28 yr old with chronic pain that ER isn't the best place to go at 3 am when she can't sleep from the pain, or the diabetic that insists on 3 hershey candy bars isn't bad for her, etc.

[SummerGarden, BSN, MSN, RN]

Plus, to add to Silverbat's post… all the investigation by those of us in the hospital setting is not going to predict the future behaviors of someone who reports supports at home or that of the support system that reports being supportive when in fact that is not the case. For example, an elderly person can report that his niece lives with him as a 24/7 caregiver, but the niece decides to go on vacation at the last minute after the patient transitions home and not get anyone to care for her elderly uncle because she is only going to be away for 1 day (and it ends up being a week). So the former patient being elderly and incapable of caring for self ends up calling 911 for food! Just some thoughts as to how it is not always the hospital case manager that is the problem.