By Melinda Young
Case managers and discharge planners in every state sometimes encounter the most challenging and frustrating of cases: the international discharge. Hospital Case Management asked Judith R. Sands, RN, MSL, BSN, CPHRM, CPHQ, CCM, ARM, a clinical consultant and author of Home Hospice Navigation: The Caregiver’s Guide, to answer a few questions about best practices in handling these unique care transition cases.
HCM: Recently, you published a paper on international discharge planning and described a complex case of a non-U.S. citizen who needed to return to the United Kingdom. How difficult is it to plan discharges for noncitizens?
Sands: There’s a growing challenge for healthcare institutions in dealing with individuals who are undocumented or who lack immigration status to acquire benefits. Many states have some kind of financial compensation through emergency Medicaid. But that typically only covers acute hospitalization. Individuals who need outpatient dialysis, physical therapy, rehabilitation therapy, nutritional care, and complex post-discharge care don’t really have options. That means the hospitals often end up picking up the tab for care for these folks to free up a bed.
If we’re talking about the typical patient who may be a migrant worker who suffers [electric shock], or a car accident, or an employment-related injury, and the employer is not reporting the injury to the carrier, or if the employer does not have workers’ compensation insurance, it’s very difficult. The patient needs post-discharge care but could be living in a group arrangement with five to seven other people sharing a room and facilities. They may be working full time and are not able to perform needed care or get the person to therapy. In a nutshell, those are the cases that I have often focused on.
More complex cases involve patients who suffer traumatic brain injuries. People who need long-term IV therapy for an infection also are challenging cases.
Discharge is more challenging if patients are on a ventilator or dialysis. Those services are available, depending on where you are geographically. In some places, they are harder to secure, and with a lack of a payment source, it becomes problematic.
Look at it in terms of social determinants of health and not only from the perspective of the patient, but also of the caregiver. If the decision to explore repatriation takes place, one of the first steps needs to be finding out if there is a family or a caregiver in that country of origin or country of repatriation who is able and willing to provide care. If the answer is yes, then you have a potential lifeline.
Failure to have a caregiver who is able, willing, and available to meet the patient’s needs places the patient at risk. We need to ensure the patient’s safety is not jeopardized. Say you are lucky enough to have a potential caregiver — what are you going to need in order for them to be caregivers? You may need to arrange medical equipment. Also, look at the legal aspects within the jurisdiction — both country and state — to see if there is an issue in trying to repatriate the patient. You will need to involve the consulate or embassy of the country of repatriation as soon as possible.
HCM: How do case managers learn how to handle these difficult international cases?
Sands: It’s trial and error. It gets into the fact that if you are living in some place like south Florida, California, or other border states like Texas, you may be doing much more of this. If you live where these cases are a rarity, you can start by reaching out to your professional colleagues and engage in networking. Whether it’s through the Case Management Society of America or other organizations, rely on your professional network. By knowing who is in your professional network and who is writing in the journals, you can reach out to people for some general guidance.
There is not one plan for handling international discharges. I spent the majority of my professional career in south Florida and dealt with quite a bit of international discharge planning, and they were all different. It could be the needs of the patient were different, or the place where the patient was going was different, along with different caregiver capabilities. The climate of being able to send patients back kind of would change.
As these cases surface, it is important to keep track of contacts, organizations, services, and resources identified, as they would be helpful in future cases. It all falls under the great umbrella of what is a safe discharge.
We’ve all heard of California folks being discharged under a bridge. In south Florida, that was not legal, and you had to have an address or safe location for the patient. We could not take patients to a migrant camp.
Case managers should be familiar with safe discharge criteria from a clinical and legal perspective and find the answers to these questions to ensure a safe discharge:
- What are the legal restrictions that affect discharge planning on a local and state level?
- What are patient assessments of discharge needs and caregiver requirements?
- What are the legal mechanisms to get that patient back? What resources are needed?
- Is the case documentation clear, thorough, and detailed? Documentation includes all contact information and reflects the patient’s status, agreement of patient/caregiver, involvement of administrative and legal approvals, and other pertinent details.
- How do you transport them back? Is an ambulance required for any part of the transport? Can you put them on a bus? If it is an international discharge, typically a plane flight is involved.
- Do they need supervision while traveling? If you put them on a bus, are you sure they’ll go where they’re supposed to go?
- Do they have the mental capacity and physical ability to make the journey?
- Is their home country or village in a war zone?
- Is their country stable, or is the patient going to be put at risk?
It’s also important to track the number of avoidable days the patient did not meet clinical criteria for continued stay in the hospital. Most case management departments track this metric, and it is an objective financial measure and an indicator of the extensiveness of the issue in your facility.
You need clear and complete documentation associated with all efforts and individuals contacted. The paper trail is extremely important.
There will be cases where someone needs to escort the patient to the country where they’ll be discharged. The case manager is not the one to travel with the patient. You may have to hire a traveling nurse or another clinical professional to manage that patient.
We had a patient for whom we had to hire an air ambulance with a nurse to send the individual, who had suffered a traumatic brain injury, to a remote village. The nurse had to provide teaching with the family, which is why it had to be a clinical person traveling with the patient.
I also remember a patient who came from Myanmar, where if they went back, they’d be imprisoned. They really couldn’t go back to their country of origin. We had to come up with a Plan B. The patient had a stroke, so we had to provide additional rehabilitative services and teach a number of caregivers who stepped in to assist in this case. We also tapped into the local Myanmar community, local churches, and adult day care options. We looked for a safe place for the person to be.
HCM: This sounds quite time-consuming. How should case managers respond when they encounter these difficult international discharge cases?
Sands: This is a chance for creativity. Just because you’ve never done this before doesn’t mean it can’t be done. It may be the time when you brainstorm and ask, “What are all the crazy ideas we have to deal with this person? Who can we tap into for assistance? Who can donate or fund medical equipment or supplies?” You ask your vendors for a medical bed or whatever equipment to help with this situation.
We often had complex discharge planning case conferences, and we’d get a group of people together. These included physical therapy, respiratory therapy, pharmacy, and others. We’d say, “OK, in order to prepare this patient for discharge, how do we consolidate the care best to get this patient in the most stable shape for a complex travel?”
This could mean we get the patient to walk five steps or get them off a ventilator. We need to do our best to get this patient closer to discharge, and we need to do it as quickly and efficiently as possible. We have to stay within the patient’s social, cultural, religious, and economic framework.
It’s also important to explore the resources the individual may have in their country of origin. Depending on the country’s particular economic outlook, they may have more resources than others.
Also, are you sending someone to the mountains or to a metropolitan city? You need to reassure them that case management is addressing their continuing care needs and has a plan in place. You never want it to look like you have abandoned someone.
To a case manager or social worker who already has a full plate, this can be daunting and the last thing they want to deal with. But there are some staff members who will beg for a case like this. They will need a lighter workload to handle the time needed to speak with consulates and embassies, gathering all the documentation and finding resources. It’s a lot of work.
My words of wisdom to managers and directors are that whoever is assigned to this type of case needs to have a lighter workload, and you should cherry-pick who gets this case. It takes a bit of matchmaking to see who has the best skill set or who is open to brainstorming and receiving collective input. Find out who is the best individual to work on these complex cases, working with various populations in a culturally sensitive way, and going the extra mile.
HCM: How do you deal with problematic family members blocking the easy solution? Recently, you discussed a case study in which the patient’s adult son did not want to take care of the patient.1
Sands: It’s about trying to understand their perspective. What is fueling the family member? Could it mean a loss of income to them if they become a caregiver? Is it the fact that they are not willing or available to become a caregiver? What is propelling them to be a hindrance?
It’s also about developing a relationship, trying to understand the barriers, and then addressing them. A lot of it is trust. Often, you’re dealing with folks who are living in the shadows, and they may be afraid of being deported.
Case managers and social workers don’t always have the time to handle these situations. They are stretched to the limit, and are always being asked to do more with less.
There is no blanket answer to this question. You have to customize the plan based on the patient’s biopsychosocial condition, the availability or unavailability of caregivers, and the degree of the patient’s continuing care needs. You also need to go through the chain of command no matter the type of facility.
Hospitals have limited funds, and there are limits on resources. You may need to go through a chain of command to get the needed resources. I’ve had to appeal to various administrative representatives of the C-suite to get a transfer blessed, get airline money, and what was needed for the patient.
Your legal department must be involved as soon as the international discharge option is considered. Failure to do so may result in reputational damages, along with adverse regulatory [sanctions], legal [penalties], and actions from accreditation agencies.
International discharges are becoming more frequent given the influx of undocumented individuals and their relocation by authorities into communities that may not have addressed these situations in the past.
Don’t be surprised. Consider a training exercise with staff to explore their level of knowledge and comfort and actions needed, based on findings.
REFERENCE
- Sands J. International discharge planning: Putting it all together. Prof Case Manag 2023;28:210-2011.
Case managers and discharge planners in every state sometimes encounter the most challenging and frustrating of cases: the international discharge. Hospital Case Management asked Judith R. Sands, RN, MSL, BSN, CPHRM, CPHQ, CCM, ARM, a clinical consultant and author of Home Hospice Navigation: The Caregiver’s Guide, to answer a few questions about best practices in handling these unique care transition cases.
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