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Leave the hospital? Now what do we do?

By Dr. Karen Kowalenko, Correspondent

The patient's family didn't understand why the hospital was discharging their elderly mother. The woman, who a week before was living independently, had suffered a stroke and now had some disabilities. She was going to need physical, occupational and speech therapies, along with other services. A return to her two-story home was not likely, at least in the near term.

"Can't she stay here until she gets better?" one of her daughters pleaded.

It's a plea I hear often.

Most people see hospitals as places where sick people stay until they fully recover, so this family concluded that someone who had suffered a disabling stroke should remain in the hospital. I had to tell them that healthcare doesn't work like that today.

Hospitals treat acute illnesses. Once the acute part of the illness is over and the patient no longer needs hospital-level care, the patient is discharged. That doesn't always mean the patient is fully recovered: it just means that the patient's physician determined the condition is stable and the patient no longer needs hospital-level care.

What do we do now?

A hospital discharge can be an overwhelming thing for spouses, families and patients already reeling from a medical crisis. There's a lot to think about and not a lot of time to make decisions. Spouses and families have to decide the patient's abilities, home situation, care requirements and whether there are people available for giving care. They may have to consider placing a family member in facility they've never seen. Seemingly overnight they have to become well-versed in various levels of care, quality, price, and the limits of insurance.

This is where a hospital's case manager and social work staff can help. Most hospitals have a case management staff - some call them discharge planners - to help families figure out the next best place for a recovering patient. Case management can help families arrange services in the community and the home, as well as help with admission into nursing homes or other facilities.

Discharge planning needs to begin the day of a hospital admission. While this isn't always the case, family members need to be mindful that most hospital patients aren't there for long periods of time. At most hospitals there is a social worker and case manager available to help families sort through patient wishes, community resources, family support, financial issues and patient goals. Discharge from the hospital is made even smoother when a patient designates one person — perhaps a spouse, family member or friend — to serve as the patient's advocate. That person can help provide information about insurance, healthcare proxy and advance directive.

New levels of care emerge

Because hospitals don't hold patients for long periods of time, alternative levels of care have emerged. For medically complex patients or those who require interventions such as ventilators, care of complex wounds, multiple long-term antibiotics or other involved care, the next level of care might be a long-term acute care hospital, such as Kindred Hospital New Jersey-Rahway, located at Robert Wood Johnson University Hospital at Rahway. Patients at these hospitals require complex, long-term acute care for more than 20 days.

Some hospitals have what are called subacute units, or skilled nursing facilities (SNFs). These units are less medically intense settings that provide the rehabilitation services patients need. At Robert Wood Johnson University Hospital Rahway, the subacute unit is called Care Connection. At Care Connection, a care plan that addresses the patient's medical and rehabilitation needs is developed by a team of nurses, therapists and other caregivers. The team then works to improve the patient's physical function so the patient can either return home or transition to an appropriate destination.

For hospitalized patients who are able to return home, there are visiting nurse and home health care services. The specialized services of nursing homes may also be an option.

Reasons for Leaving the Hospital

Being told a patient will be discharged days after a life-threatening illness may sound cold, but there are good reasons for getting patients out of the hospital. Patients who are hospitalized for long periods of time can develop infections and life-threatening pneumonia. They risk blood clots and hospital-related dementia. Still another factor is insurance reimbursement. If a patient no longer meets the criteria for acute illness, Medicare and other insurers won't reimburse a hospital for its services, leaving the hospital or the patient to pay the bill.

A sudden accident or illness is devastating and being hospitalized is traumatic. But working with a discharge planner or case manager from the first day of hospitalization can help make the transition from hospital to home more seamless and the care more effective.

Karen Kowalenko, DO, is a family practitioner. She is co-director of medical management at Robert Wood Johnson University Hospital at Rahway. She is currently president of the New Jersey Osteopathic Association.

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