Discharge Planning

Discharge Planning

“Discharge planning starts at admission”

This is a common adage we ascribe to in hospitalist medicine. Waiting until the person is “ready to go” to start planning for their exit from the hospital is road paved in delays, problems, and broken expectations. After a patient discharges from the hospital until they again see an outpatient provider is a high risk time. New diagnosis, medications, testing results, specialist involvement, follow up appointments have all come together befuddle the patient right as they are set out on their own. I hope this section helps to demystify the process and provide you with direction to ensure things don’t fall through the cracks after discharge.

Discharge location: “Where are you going?”

  1. Home – either alone or with family. Easiest and most straight forward solution. Checklist:
    1. Am I well / strong enough to be at home?
      1. If not who is going to take care of me?
      2. What about when they are working? Out of town?
      3. Do I have access to groceries, medications, communication (phone, internet)?
    2. Do I have all needed equipment? (ie: walker, bedside commode, shower chair, hospital bed, wheelchair, toilet raiser, grab bars for bathroom, Hoyer lift, etc…)
    3. Do I have a RIDE HOME and a KEY TO GET IN?
      1. Friend or family picking you up? Are they available? What time are they coming?
      2. Commercial (medical transportation company, taxi, Uber/Lyft?
        1. Insurance often DOES NOT pay for transportation home (there are exceptions)
    4. Do you have clothes to wear?
  2. Home with Home Health – Same as above except now a physical therapist, occupational therapist and nurse will come visit. Generally 2-3 times a week for 30-60 minute visits.
    1. These are NOT personal care aids who provide custodial care (bathing, dressing, etc).
    2. Personal care aids are private pay out of pocket; insurance does not cover this (except some a long-term care policies and Medicaid)
  3. Skilled Nursing Facilities (SNF) – there are many around. Each has long-term care (traditional “nursing home”) and acute care facilities. Medicare and most insurances will pay for 21 days in a SNF after discharge.
    1. VA State Medicaid is the only form of insurance which pays for long term care (living a nursing home).
    2. That patient has to be both willing to go and willing and able to participate in therapy.
      1. If unable to participate due to mental abilities (ie: dementia, confusion, etc) or physical (contractures, cannot work with hospital therapist) then insurance won’t pay.
      2. The patient must agree to go. Many times I have seen a patient’s children try to force their parent to a SNF. Often they invoke power of attorney to try and force their parents. Power of Attorney is only applicable when the patient is unable make a decision; not when they make a decision you do not like. Mentally capable adults are allowed to make medical decisions we disagree with. 
    3. Have a plan where you will go (home) once therapy is completed in 3 weeks.
    4. Expect to do about an hour of therapy most days of the week. This is highly variable based on patient’s individual need and facility staffing. 
    5. You live there while doing therapy. You are able to leave to attend doctors appointments or go our with your family as you desire. 
    6. Staffing is less than in a hospital. If you require more care than you did in a hospital consider privately hiring a private duty care aid to supplement the care. 
  1. Medicare and other insurances require the patient is provided a choice of facilities (Medicare Choice Letter).
    1. US News and World Reports Nursing Home Rankings for Richmond
    2. Medicare Comparison Website
    3. Website rankings are highly variable and like most online rankings unhappy people tend to leave more reviews than happy people
    4. If possible have a family member tour the facility to get a feel for it.
    5. Often location to one’s home and facility bed availability influence choice. 
  2. Inpatient Rehab (IPR) – the highest level of post-hospital rehab. Medicare requires the patient tolerate 3 hours a day of therapy and needs physician onsite care.
    1. Around Richmond IPRs:
      1. Johnston-Willis – 5th floor of Johnston-Willis Hospital.
      2. Sheltering Arms – Broad St in Short Pump
      3. Encompass – has 2 locations in Richmond and Petersburg. 
    2. Process of getting into IPR:
      1. Physical and Occupational Therapy see and recommend IPR level rehab.
      2. Doctor places order for IPR (order is for case manager)
      3. Case manager obtains choice of IPR from patient
      4. Case manager submits the therapy notes and other clinics information to the IPR for review.
      5. Staff at IPR reviews notes and either accepts or declines
      6. If IPR accepts that facility then submits a request to the insurance company for approval. MOST IPR DENIALS ARE HERE FROM INSURANCE. Some insurances (Humana, United Health; have an effective 100% denial rate).
      7. If insurance approves IPR benefit the patient is transferred there when a bed is available (can go by medical transport or private vehicle).
        1. If insurance denies IPR benefit patient generally go to a SNF or go home with home health.
      8. Takes between 2-5 days usually for process to complete (most is waiting on insurance). 
  3. Long-Term Acute Care (LTAC) Hospital – a specific type of hospital made for patients who stable but remains too ill to go home or to other rehabs but do not require ongoing acute hospitalization. Estimated lengths of stay are 3-4 weeks, instead of 3-4 days. Weaning from a ventilator, prolonged pulmonary or cardiac recovery, complex wound care, brain injury, recovery after catastrophic illness are some examples
    1. Select Specialty Hospital in Richmond is the local LTAC
  4. Hospice – more detailed information on hospice is found under the hospice topic. In short most hospice is done at home. Medicare covers hospice care at 100%; and thus sets the regulations.
    1. Home Hospice – the patient goes home and a hospice nurse and nurse’s aid come out to make visits several times a week. Care is performed by the patient’s family
      1. There are some Hospice Houses – private residence where several hospice patients live and staff care for them. There are few available. 
    2. Hospice in a facility (SNF, assisted living) – the patient lives at he facility and hospice comes in and performs visits the same they would at home.
      1. Medicare DOES NOT cover room and board for hospice care at a SNF. They cover the medical care; but the patient must private pay for room and board (generally several thousand dollars a month).
    3. General Inpatient Hospice (GIP) – this is for patients who death is imminent (prognosis a few days; < 7) whose symptoms cannot be managed outside of a hospital setting. They require IV medication for symptom control and constant nurse attention.
      1. From CMS: “General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting. GIP is not intended to be custodial or residential. Once a beneficiary’s symptoms are stabilized, or pain is managed, he/she must return to a routine level of care. The beneficiary may remain in a facility due to safety, but Medicare will not pay for GIP unless the beneficiary is in need of this level of care, and it is clearly documented in the medical records.”
  5. Inpatient Psychiatric Facility – hospitals are the safety net for an acute mental health crisis in the United States. Often patients are admitted to medical hospital to stabilize the consequence of their mental health crisis (ie: suicide attempt, acute substance intoxication or withdrawal, etc). Once this stabilizes and after assessment by a psychiatrist they may be transferred to an inpatient psychiatric hospital (Tucker’s Pavillon at Chippenham Hospital) for ongoing psychiatric stabilization.
    1. To be admitted to a psychiatric hospital the psychiatrist HAS TO RECOMMEND ADMISSION. The patient, their families, nor the medical doctor can overrule this decision.
      1. If the patient goes voluntarily they generally stay 3-7 days then discharge home.
      2. If the patient DOES NOT WANT TO GO they can be committed to the psychiatric hospital involuntarily. This is most common after suicide attempts which effectively mandates an inpatient psychiatric stay; but the patient does want to go.
        1. If the psychiatrist recommends and inpatient admission; and the patient refuses then Richmond Behavioral Health Authority (RBHA) is involved. Their representative conducts an assessment (by phone or in person) and has the final decision on admission or not (overrules everyone else, including doctors). 
        2. RBHA does NOT think admission is warranted; the patient is discharge home.
        3. RBHA feels admission IS warranted. They contact a magistrate (judge) who issues a Psychiatric Temporary Detainment Order (TDO). This is a legal order compelling someone to inpatient treatment against their will. Security / Police then escort the patient to Tuckers for care. DOCTORS CANNOT COMMIT PEOPLE, ONLY JUDGES.
          1. Because this is a legal order it becomes part of one’s legal record and can be used in court. Also many legal forms require one’s attestation they have never been involuntarily committed to a psychiatric hospital (for instance concealed carry handgun permits). 
    2. Once it has been determined a patient is going to Tuckers they must wait for a bed. At Chippenham Hospital and Tuckers this is often several days due to patient volumes.

Discharge planner: Case Manager / Social Worker

Case Mangers (Social Workers) are the under appreciated lynch-pin of discharge planning. For any of the above discharge plans to work they have to arrange it. Most hospital units have 1-2 social workers on that floor; and nearly everyone there needs something from the list above. Their job is make these discharge arrangements; and do so within the confines of Medicare, Medicare, private insurance, no insurance, rehab facility, patient and family demands. 

Making the case manger’s life easier facilitates and expedites the patient’s care:

  1. Thinking about what your discharge plan will be; if other than going home alone start planning for what you want. 
  2. If need a facility; start looking them up online. Have family members visits if able; come up with a list of 2-3 places ranked in order of preference
  3. Look up online or contact insurance company to figure out what your after hospital care coverage is. Did the hospital get your insurance card on admission?
  4. How are you going to get there? Plan for a ride calling family/friends to ensure they are available to pick you up. If need medical transportation let the case manager know that early.

Discharge Process: 

You are medically ready. Discharge arrangements have been made. Ride is in place. How do you actually get out the hospital?

  1. Attending physician places a discharge order
    1. Most patient are admitted under the hospitalist making this physician the attending. It is not unusual for a consult to tell a patient they are “ready to go” but it is still the hospitalist who has to discharge the patient. They ensure the medications and above discharge plans are completed before the patient leaves.
  2. Attending physician completes the medication reconciliation. This combines all of your home meds, hospital meds, and any new meds into one list telling the patient exactly what to take when they get home.
    1. More often than not this list is inaccurate when I discharge a patient. Much effort is expended in correcting it. Medication errors and drug-drug interactions are leading cause for patient harm and this is a prime set-up for it. 
    2. PRIOR TO DISCHARGE REVIEW YOUR HOME MEDICATIONS WITH THE NURSE ENSURING ACCURACY OF THE MEDICATION RECONCILIATION.
  3. Attending physician completes the discharge note which is the information for the patient. 
  4. The nurse reviews the discharge medication reconciliation and discharge note with the patient / family.
  5. The nurse removes the patient’s IV and if needed the cardiac monitor leads.
  6. The patient is taken in a wheelchair down to the discharge location.
    1. Discharge pick-up is by the cafeteria and Chick-fil-A. 
    2. Patients who need to wait several hours for a ride are taken to wait in the discharge lobby which is in the main hospital lobby by Starbucks. This frees up the room to be cleaned so patients waiting in the ER can get up to the hospital floor.

Home oxygen arrangement:

It is common for patient’s to need oxygen after discharge when they go home. Medicare and other insurance companies have set for the following criteria: within 48 hours of hospital discharge the patient’s room air oxygen saturation must be < 88% to qualify for home oxygen. Insurance won’t pay for oxygen because you want it, feel better with it, or need it “just in case.” 

Discounted Medication Websites:

GoodRx

RxSaver

CostPlusDrugs

Amazon Prime Rx – RxPass 

Leaving the hospital is a multi-step process which several providers all playing different roles to ensure the patient is sent home safely and informed. The goal is to have the patient out of the hospital within 2 hours of the doctor discharging the patient.

Doctor – make the determination the patient is medically ready for discharge. If multiple providers are involved in the patient’s care they come to a consensus on when to discharge.

Doctor must enter the discharge order addressing topics like: diet, activity, follow up, any restrictions, special instructions going home, things to look out for, etc.

Review all medications including home medications, new medications, any changes to these and send new prescriptions into the patient’s pharmacy (done electronically). Certain medications (controlled substances, opioids) have restrictions on who and how many can be prescribed at once.

Compose the patient’s discharge note combining the above information into the packet given to the patient. Compose the discharge summary on the patient’s hospital stay so other providers (PCP, future doctors) understand what happened. This is sent to patient’s PCP by the medical records department.

Nurse – prepares the patient for discharge by: giving any medication prior to leaving, removing peripheral IVs, cardiac monitor, etc. Helping the patient get dressed and collect their belongings and coordinating with the patient’s ride when and where to pick them up.  A specialized discharge nurse sometimes helps the primary nurse to expedite the process. Reviews the discharge packet and medications with the patient to ensure all questions are answered.

Case Manager – secures any equipment (ie: home oxygen, a walker) and services (ie: home health) the patient needs.

Tips for the patient to improve discharge: make this a full page check list patient’s can fill out.

  1. Once admitted to the hospital develop a plan for going home:
    1. Where are you going? (home, stay with family, rehab center)
    2. How will you get there? (family drives, social worker arranges transportation)
    3. Do you need anything? (bedside commode, walker, wheelchair, hospital bed?)
    4. Do you already have or need home services? (home health nursing, physical or occupational therapy)
    5. Do you have enough medications at home? (refills needed, run out of meds)
    6. Do you need a work / school note?
    7. Do you have clothes to wear to go home? (if not family should bring in)
    8. Do you already have any scheduled doctor’s appointments to follow up with after discharge?

Access to patient portal to review records.

Insurance qualifications for home oxygen is <88% on room air.

If patients are found to have low oxygen levels (hypoxia) when sleeping home oxygen can be arranged prior to discharge; however, in order to get a CPAP/BiPAP/Trilogy machine for sleep apnea a sleep study must be done as an outpatient.