Discharge Planning Quarterly
Proactive approach increases social work staff
Patients come from three states, live in rural areas
Patients at King's Daughters Medical Center (KDMC) in Ashland, KY, come from a three-state area creating challenges for the social workers who must find a safe discharge destination for patients, many of whom live in rural areas.
By taking a proactive approach to overcoming discharge barriers, the department has proved its worth and has grown from six social workers a few years ago to 18 today. Two new positions were added last December.
"One of our organization's focuses is on length of stay and throughput management; the administration recognizes the value of what we contribute to the process. They realize that discharge planning takes a lot of work. It's more than just identifying the plan. It's carrying out all the steps to make a discharge plan happen," says Miranda Tussey, MSW, CSW, director of social work at the 385-bed hospital.
The department's goal is to see the patient on the day of admission, assess him or her for post-discharge needs, start the discharge planning process, identify the barriers to discharge, and then work to overcome them, she explains.
The social workers have familiarized themselves with the capabilities of vendors in the area and the areas they serve. They meet weekly to discuss issues of concern and tap into the hospital auxiliary's emergency fund to provide equipment for patients ready for discharge who have no payer source.
But it's the proactive and creative approach to discharge planning that pays off, Tussey reports.
"We are constantly looking for ways to overcome roadblocks to discharge. I tell my team that there is a solution to 99% of their problems with discharges but they have to constantly ask themselves what else they can try," she adds.
Here's an example of how the social workers facilitated the discharge of one patient who might otherwise have stayed 60-90 days.
The woman was admitted from a personal care home that couldn't take her back because of the complexity of her health care needs.
She was a good candidate for nursing home placement but was incapable of making her own decision to consent to the transfer and had no guardian of record.
"Adult protective services will issue guardianships in an emergency situation, but she was in a safe environment and it was going to take 60-90 days to have a guardian appointed for her," Tussey says.
Using "good old-fashioned investigative techniques," the social worker contacted Medicaid to find out where the patient previously had been hospitalized, and then contacted the hospital. She found that the woman had been under adult protective services in Charleston, WV, but they had lost track of her when she was transferred to the Ashland facility.
At that time, a friend from the church had been the patient's guardian. The social worker started tracking her down, using Internet search sites. She found an address but no telephone so she contacted the local sheriff's office who got the woman to call KDMC.
"She had lost touch with the patient after she was transferred to the personal care home but she was willing to help us when we needed it," Tussey recalls.
As a result, the woman was able to be transferred to an appropriate level of care, saving the hospital thousands of dollars.
At KDMC, the case management and social work departments were separated in August 2007 but the two disciplines still work as a team on the units.
Social workers handle all the discharge planning and education. The case managers focus on the clinical management of the patient.
"We work as a diode on all the units. The case manager is talking with the physicians and identifying the next step in the continuum and the barriers to meeting it. The social workers are setting the discharge plan in motion and doing support and education to help prepare the patient and family for discharge," Tussey says.
The department has 18 social workers, most of whom are master's prepared. They cover the acute care hospital, emergency department, behavioral medicine, and the hospital's skilled nursing facility and rehabilitation unit.
Each unit has a census meeting each morning and a daily discharge meeting to review all the patients on the unit and their discharge plans. The meetings are attended by case managers, social workers, and the charge nurse.
Since patients come from such a wide area and three different states, the social workers must work with post-acute vendors in Ohio, Kentucky, and West Virginia.
In addition, each state has different standards for publicly funded patients and its own screening tool for a history of mental health.
"As a department, we work hard to keep up with the standards we have to follow in each state. We stay familiar with all vendors in our catchment area so we know what areas they serve and what capabilities they have. We know what their stipulations are when it comes to new admissions and we make sure that we meet them," she says.
For instance, one skilled nursing facility has a 3 p.m. cutoff for new admissions.
In that case, the social workers work assertively with nursing, case management, and other disciplines to make sure there is no delay in discharge that would mean patients being discharged to the nursing home would have to stay in the hospital one more day.
Tussey holds a weekly staff meeting with the social workers and invites a post-acute services provider to give a short presentation about their company, their service area, and any changes in their admission requirements, such as when a nursing home adds beds or changes the types of beds they have.
"We ask the vendors to keep their presentation short and to the point. We want to know what their services are and what areas they cover. The meetings help us keep abreast of what the vendors have to offer," she says.
The social workers keep up with which companies offer service only locally and which ones have branches nationwide. The information comes in handy when they arrange services for patients outside the hospital's catchment area.
For instance, they were able to set up home oxygen for a truck driver who lives in another part of the country and had an accident while driving through Kentucky.
In another instance, a man who had retired to Florida had a heart attack while visiting in the area and needed services in his home state.
"Our social workers are masters of the Internet. They use it to search for information to find placement and services for our patients who live in remote areas," Tussey says.
For instance, there may be a patient who lives in Ashland and has children in Lexington and the social worker needs to facilitate nursing home placement in that area.
The hospital has its own health and medical equipment agencies but the social workers always offer patients a choice, Tussey says.
"When patients are not from this area, our home health and medical equipment agencies can't serve them and we have to know what providers are out there to serve the needs of our patients," she says.
If a patient is being discharged to a rural area and chooses a durable medical equipment company that doesn't have a home base near the hospital, KDMC's equipment company will loan the patient a portable oxygen system that he or she can use to get home and bring it back when he or she comes for a follow-up visit.
"Our primary goal is to identify barriers early and prevent discharges from being held up. We seldom have delays in nursing home placement. It goes back to identifying the need on admission and beginning work from the outset," she says.
The social workers keep the facility where a patient is likely to be transferred updated on the patient's clinical status during the hospital stay and work proactively to facilitate placements, even though the discharge plan may change.
"There are occasions when the patient is adamant about going home and the family is adamant about taking him home but the day before discharge, they change their mind. We've planned ahead and eight out of 10 times, we can get the information to the receiving facility and get the patient out in time," Tussey says.
Tussey encourages her staff to brainstorm with colleagues to solve challenging discharge problems.
"Sometimes when people are heavily involved in a situation, they can't see the forest for the trees," she says.
When there were only six social workers in the department, the team often ate lunch together and brainstormed on problems.
"As we've grown, it's harder for people to get together on a daily basis. Monthly meetings aren't enough because they deal with organization goals and there's not a lot of time to talk about individual cases," Tussey says.
That's why the weekly department meetings are so important, she adds.
"The social workers all know that if they have a discharge barrier, they'll have an opportunity to talk about it with their peers every Wednesday," Tussey says.
Tussey chooses a pertinent topic to discuss at each meeting. It may be IV antibiotic referrals, nursing home placement, or teamwork.
"We talk about daily operational things to make sure everybody is on the same page," she explains. "This process seems to work better than distributing the information by e-mail."
When patients need post-discharge care but don't have the means to pay for it, the social worker department can tap into the hospital's charitable fund.
For instance, the fund has been used to provide durable medical equipment and home health services for some self-pay patients who have open-heart surgery and for home health wound checks.
"We are fortunate that we can write proposals to provide the care the patients need after discharge. This helps us get these patients discharged in a timely manner and avoid readmissions," Tussey says.
Patients at King's Daughters Medical Center (KDMC) in Ashland, KY, come from a three-state area creating challenges for the social workers who must find a safe discharge destination for patients, many of whom live in rural areas.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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