Start discharge planning early
Planning for the discharge of a patient as soon as that person enters the emergency department is not heartless or an effort to push patients out the door as a cost-saving tool, says Patrick J. Hurd, JD, an attorney with LeclairRyan in Norfolk, VA. Rather, it is a critical component of safe, quality patient care and can help head off difficult situations such as the controversial discharge of an illegal immigrant in the recent Florida case.
"Too often, hospitals are reluctant to begin addressing such issues with an uninsured emergency room patient for fear that they may run afoul of EMTALA. That's misguided," Hurd says. "The patient presenting to the emergency room requesting a medical examination or treatment for a medical condition must receive an appropriate medical screening examination and receive stabilizing treatment as necessary and as mandated under the statute. This does not mean that the hospital cannot begin the process of determining how best to assure a safe discharge of the patient from its facility. That's not discriminating against the uninsured patient. It simply means that achieving that goal may be more problematic because of limited options available to the acute care facility."
If the patient has family members with him or her, then treating physicians and nurses, supported by patient relations, should begin a dialogue with them about post-hospitalization care and their capacity to meet those care needs, Hurd says. If there is a possibility that the patient is or may be unable to direct his or her own care, and in the absence of an advance directive or durable medical power of attorney, the hospital should move quickly to assure that an advance directive or power of attorney is executed, or guardianship appointment proceedings pursued.
"Effective communication with the patient and family members is especially critical in such early stages. Reassuring them that the hospital's focus is on providing proper acute care to treat the illness/injury should be accompanied by discussions regarding 'best next steps' as soon as it appears that rehabilitation or long-term care may be necessary," he says. "This should not be left solely to case management or patient relations staff. The treating physician plays a critical role in such communications."
If the physician is reluctant to do so, the hospital risk manager and patient safety officer can help coach the doctor on how best to address the subject. This helps place the post-hospitalization steps in the context of a continuum of care rather than a stark and sudden conversion from one status to another, Hurd says.
If the uninsured patient is incapacitated and has no family members, or any relatives identified are not capable of rendering decisions on the patient's behalf, then Hurd says the early appointment of a guardian ad litem is vital. Attention should be directed toward an attorney with experience in elder care law, health care law, or similar matters. Appointment procedures vary by state, so it is advisable that hospital counsel be consulted.
"The guardian, hospital staff, and the treating physician must then work cooperatively on assuring the proper discharge disposition of the patient," Hurd says.
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