When did LTC/ALF's administrations start calling the shots?

[Antikigirl, ASN, RN]

So, as most of you know I use to work at an ALF/LTC for four years...I certainly know their sides to the story. But now that I work in hospital, tending many of the same pts I cared for there...I noticed a new trend. A new trend that is actually making my blood boil!

I had a patient recently that was admitted from a ALF with breathing difficulty and she wound up having the flu. She was treated, cultures came back negative, and was to go home. HOWEVER, the facility said NO and that they wanted to talk to the state health department before she would be allowed to come home. Okay..and this will do what? Notify them that someone that HAD the flu was there...bet there are more since the pt got it from someone there! Anyway...

Basic point..this lady spent an additional 2 days in the unit with us waiting for the facility administration to do whatever it was they were doing. The patient was officially discharged two days before...and now is sitting in limbo at our facility...use to hands on care for everything which we can't do very well (I mean EVERYTHING...she doesn't need to lift a finger for any need...very sad, don't they realize what that does to people!)...and feeling like a piece of diseased trash that can't go to her apt home (she told me how she felt!).

I felt so horrible for her, and tried to make her stay as comfortable as possible. But the underlying fact that she felt abandoned, shunned from her friends and home, and powerlessness to do anything about it was very strong. Poor gal...she finally was let go home and she had such mixed feelings about returning vs being happy to get to her apt and friends!

On another note, who paid for this??? Two day "layover" in a med surge bed? I know medicare is going to foot the bill, or perhaps the state...and for what??? Shouldn't the facility be charged since she was cleared medically to go home, she pays rent to that facility in order to stay there, and in essence was discharged so logic would dictate she could go to her APT! I think the faclity owes the cost of the two days...not the taxpayers! Let alone fixing the emotional and spiritual damage it caused!

We have run into this probelm time and time again, but it is increasing in number significantly over the past few months. LTC's or what not refusing the patient for whatever reason..temp or perm...and medicare having to foot the bill till someone finds placement while they wait in hospital. Some places will even say no to certain medications or drugs because they feel that if you need some of these medications...you shouldn't be with them...we are talking antibiotics for UTI's...or some that aren't covered by medicare!

I am sorry, but once you are discharged from a facility you are discharged! And you should be allowed to go home within reason (not if you are contagious or something like that) to the place you or your loved ones PAID FOR to live (and even if medicare...it is cheeper than a hospital stay so fiscal sence there, and heck...you sign an agreement that if medicare doesn't pay you do anyway...so it is still your place!)! I don't think that facilities like this should be the ones calling the shots over the hospital or MD!

THOUGHTS????? VENTS???? STORIES?????

[VivaLasViejas, ASN, RN]

OK, I'm going to play devil's advocate here, because I sit on the other side of that ALF administrator's desk, and there are two very good reasons why I insist on speaking to the discharge planner before a resident ever crosses the threshold after a hospital stay.

#1: If the resident has a need we cannot meet. There is a lot of confusion between ALFs, RCFs, and SNF/ICFs; in fact, these very different types of facilities are often lumped together by people outside community-based care, who tend to assume they all offer the same services. Not so! I'm the DON for a 42-bed ALF, and we don't deal with IVs or PICC lines, sterile dressing changes, new amputees, two-person transfers, acute psychiatric issues, or total feeds. Assisted living residents must be what's called "stable and predictable" before returning home; if they aren't, a nursing-home stay is a must.

#2: Hospitals often discharge people too sick, too quick. I can't count the number of times I've sent someone who was ambulatory and alert to the hospital for a short-stay procedure or with a touch of pneumonia, and gotten them back so confused, combative, or weak that we can't manage them. I know they have to go somewhere, but if we can't take care of them, they don't belong in the facility.

ALFs are sort of a halfway house---our residents are neither completely independent, like those who live in retirement communities, nor totally dependent like the majority of those residing in nursing homes. We don't have the staff nor the resources to care for the acutely ill; in fact, most don't even have a licensed nurse on duty 24/7. Now I don't know about anyone else, but I wouldn't want MY elderly parent going home to a facility where he or she would be checked on every 2 hours at best, and maybe once or twice per day at worst. Neither would I be able to sleep knowing he or she was alone in an apartment, too weak to get up to the bathroom without two aides to help (and they only staff one caregiver at night).

THAT'S why we sometimes get edgy about accepting residents back after hospitalization. It's one thing when someone is discharged to their own home in bad shape; quite another when "home" is a licensed facility providing care (within certain limits). We don't do it to be mean or to get out of taking back a resident we consider undesireable; we do it to protect the resident, and yes, to protect ourselves. Try not to be so quick to judge; we're all on the same team!