New at Case Management and patient discharging

Nurses General Nursing

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I have been a geriatric nurse my whole career and at times have been an MDS coordinator (not a big stretch) but now I am at a hospital which has a long term care unit and sub acute unit blended and while I feel at home on the long term care unit I feel lost on the sub acute unit when it comes to discharge planning - some of the discharges are easy- no big deal but then we get some where the patient has just been evicted from their home, and her family is dysfunctional and I just don't feel good about sending her home to her family , she won't get the care she needs- she is her own decision maker and doesn't want to stay in the long term care unit even though she has medicaid.

While I feel I am starting to get the hang of it it seems like there is always a hitch in 2 out of 3 discharges. I want them all to go smoothly but something always seems to go wrong- is it me or does this happen every where or do I just need more training and time.? Should I stick with it? I love my job but get frustrated.

CseMgr1, ASN, RN

1,287 Posts

Specializes in Case Management, Home Health, UM.
Originally posted by elle4pets

While I feel I am starting to get the hang of it it seems like there is always a hitch in 2 out of 3 discharges. I want them all to go smoothly but something always seems to go wrong- is it me or does this happen every where or do I just need more training and time.? Should I stick with it? I love my job but get frustrated.

And it WILL go wrong, for long gone are the days of the reliable extended family, and a healthy health care system, geared to meet the needs of an aging population. I've been in Case Management in one way or the other for over 20 years, and I've had discharge planning issues with probably 80 percent of my patients. It is VERY frustrating, when you are trying to obtain a favorable discharge outcome, and wind up feeling like you are butting your head against a wall.

The only words of wisdom I can give you from my own experience is to make sure that you document, document, document! That way, you can be satisfied with yourself, that you did everything in your power to effect a favorable outcome. There are just too many variables in this day and age, for ANYTHING to go smoothly anymore.

Go easy on yourself. It is frustrating, but can be very rewarding at the same time. :)

River

13 Posts

In the hospital where I worked we always called in Social Services to help make arrangements for our dificult discharges. it seems the they had access to resources we nurses aren't aware of. They most often succeeded in finding a place for the patients.

elle4pets

6 Posts

My social services liasion tries to assist but she gets so busy with the other floors that she puts it back in my lap- I appreciate the words of wisdom and encouragement though! So I won't give up hope yet!

Agnus

2,719 Posts

I know this is not what you are asking and I am not in your shoes. But your situation made me think.

If all discharges were easy and simple we would not need discharge coordinators at all. The floor nurse could do it.

You have a tough job. Don't beat yourself up because it is not an easy job.

Specializes in Med/Surg, ER, L&D, ICU, OR, Educator.

I share this postition as part of my job as well...and feel your pain! Families are so complicated! I really do have a new respect for my totally functional siblings (well...mostly) and non-demanding (in most ways) and realistic parents.

In our rural hospital, we have no social worker, so my coworker and I try to "pinch-hit" at this as well (we are both BSN's with no social work education, although some graduate classes in case management). Our county family services dept. is very user-unfriendly, and as a rule, of no help to us. EEEKK!

It seems, in some ways, like we are the gatekeepers of the hospital. "This patient does not qualify as an acute care patient any longer", "ICU is an inappropriate level of care for this patient after this long", "Will the patients quality of life be enhanced by that procedure", "Do you think it's time to begin TPN on that patient, since extended NPO is apparent", "A discussion about advanced directives is needed soon", "Will you make time for a family care conference so that all the kids are hearing the same message, and can hear your prognosis and what it will take to safely care for Jack at home", "I don't think her home living arrangements are working for her any longer", etc.

I often feel undereducated in this arena. I've attended a seminar titled "Discharge Planning", that was totally inadequate, and addresses only patient health...not disposition and/or services and funding of such services. I actually have yet to find a book that even takes all the nuances of this job into account. (I'd love recommendations, if anyone has any). The job has been learned by "hard knocks", and from insight gleened by prior discharge planners. It's a stressful and frustrating, although sometimes, extremely rewarding position. I'm very happy that it is only 1/2 of my job, as it is quite energy expending, and emotionally involving.

River

13 Posts

Accessing some of the home health agencies in your community might be another resource for you. Often they will have Social workers on thier staff that could help. Do your home health agencies ever sit in on discharge planning before the patient goes home? Do they come in once the referral has been made to assess the patient, family and situation? Just an idea? :rolleyes:

Specializes in Med/Surg, ER, L&D, ICU, OR, Educator.
Originally posted by River

Accessing some of the home health agencies in your community might be another resource for you. Often they will have Social workers on thier staff that could help. Do your home health agencies ever sit in on discharge planning before the patient goes home? Do they come in once the referral has been made to assess the patient, family and situation? Just an idea? :rolleyes:

Perhaps we are too rural for all this assistance and bigger hospitals can't imagine having no one to call. I've done a stint in our Home Care dept. (not my cup of tea, but quite helpful as to learning all they have to offer) and, as I said, we do not have a social worker on staff. They are a dept. of our hospital, and we share staff (many of our nurses work in more than one dept., and wear many hats). Of course, a Home Care nurse assesses the patient, family and situation, just as the Discharge Planner does, and information is exchanged freely. We all share everything we know, or what has worked for us in the past. It's all about the patient.

One nice thing about being "small town" is that we all know each other...the owner/DON of the residential assisted living development, the DON's of the area nursing homes, the owner/operator of the Personal Assistance Care Providers agency in town, etc, and we all share info and offer each other assistance freely too. It's just our county social workers...they are probably overwhelmed with work, I don't know.

I was just looking for some good reading material...something with a broader scope, I guess. The obvious avenues have been, and continually are, used.

River

13 Posts

ceecel.dee, my reference point comes from a small town, rural area. The hospital is less than 80 beds and the town is less than 7,000 people in the whole surrounding area, with the closest large city over 90 miles away through mountainous roads. :rolleyes: I wish you good luck with your situation.

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