Discharging frail elderly population
Diligence by social worker can make the difference
Preparing to discharge a frail, elderly patient is a task that shouldn't be taken lightly in any setting, but for Priscilla F. Cutler, MSW, LICSW, MFA, ensuring that an elderly patient's safety net is in place can prove challenging in a mountainous, lightly populated area of New Hampshire.
"We work with home health and a visiting nurse service, and they do a good job, but we don't always have enough control over some of the more rural pockets, and sometimes we have trouble getting people in there," says Cutler, a clinical social worker at Monadnock Community Hospital, a 62-bed acute care hospital in Peterborough, NH, with a population of more than 6,000. "It can be quite challenging."
Dealing with a patient with lots of needs takes creativity to get the most out of limited staff and equipment resources.
"Frankly, as a team we have very good relationships and very limited resources," she says. The collaborative team that plans patient discharges at Monadnock Community comprises a physical therapist, occupational therapist, social worker, nurse, and doctor.
"Our average stay is supposed to be about 96 hours, but we have skilled nursing at the hospital, so if we see someone is very deconditioned either they came in very deconditioned or they became deconditioned while in the hospital we can switch them to skilled nursing without having to go to rehab or a nursing home, which is very helpful," she explains. "The stumbling block for us is coordination of equipment and service in the home."
But proving that good discharge planning can trump a lack of resources, Cutler says the recidivism rate for frail elderly patients who are discharged from Monadnock Community "is pretty low."
Shoot for Plan A, but have Plan B ready
"We really want to anticipate what problems are going to happen, and to do that we coordinate with the family on the very first day, and then every day maybe more than once a day with the family until the patient is discharged," she says. "We want the family to come in and go over [the plan] before the patient is discharged."
She says it's not uncommon for patients to enter the hospital anticipating that they'll be discharged home with no complications, but once the situation is assessed, the family realized they hadn't taken into account the remote location of the patient's home, or the flights of steps that have to be navigated once the person gets there.
"You want to troubleshoot before the discharge," Cutler adds. "You want to pull in that family and friends, and get them in the loop and find out what their time commitments are, what they're willing to do, what shopping or driving they can do.
"Because a lot of times, the family lives across the country, and maybe the person has few resources, or they have no family, so you have to find a friend, a neighbor, someone in that person's personal life, and work it out."
And most important: "What does the patient want?"
"We find out what the patient's 'Plan A' and 'Plan B' are, and we operate with those in mind at all times, but we know we sometimes have to go to Plan C, D, or E," she admits.
That's where being a social worker comes into play.
"The patient might be insisting on going home, and the members of the team see lots of questions about that, that it might not be the best option for that patient, but that's what the social worker brings into it you look at it, look at the patient, and you want the patient to get what's best for them," she explains. "We certainly raise safety issues, especially when a patient wants to go back and live in a place that others on the team are afraid won't meet his or her needs, but the social worker is left to advocate for what the patient wants."
While staffing doesn't permit Cutler and her colleagues to routinely follow up with patients after discharge, they make it clear to patients and families that they are there if needed.
"Every plan can fail," she points out. "The team may say 'We don't think this plan will work,' but the family or the patient insists, then they get home and realize the next day or within a few hours that they can't do it. And when that happens, we help facilitate the best we can."
Preparing to discharge a frail, elderly patient is a task that shouldn't be taken lightly in any setting, but for Priscilla F. Cutler, MSW, LICSW, MFA, ensuring that an elderly patient's safety net is in place can prove challenging in a mountainous, lightly populated area of New Hampshire.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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