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Deborah G. Schuss

The ‘quicker and sicker’ exit strategy

By Deborah G. Schuss
July 30, 2009

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WHEN MY cellphone rang, I expected the emergency-room doctor with an update on my father’s condition. Diagnosed with pneumonia and an apparent infection, my dad was in a holding area while waiting for a hospital bed to clear.

“I need your plan for discharge,’’ announced a hospital official whose name I had to extract.

So went my introduction to the case manager, a hospital fixture and healthcare’s equivalent of the meter maid. Pat’s no-nonsense demeanor as she proceeded with her revenue-focused mission of orchestrating my father’s departure even before his formal admission is emblematic of what’s often missing these days for patients’ families: a genuine sense of caring to accompany the care.

It wasn’t so long ago that a hospital social worker would meet with family caregivers a day or two before our loved one was discharged; patient advocacy was the dominant theme, as this person sorted out post-hospital challenges and weaved a plan to cushion patients while propping up their caregivers.

Now, hospitalizations beyond a day or two are rare, and there is an army of Pats lined up at the command post to bounce patients from their hospital beds quicker and sicker: One day they are on oxygen and IV drips, the next day the ambulance driver is depositing them at their doorstep. The lucky ones have relatives or friends to step in as caregivers and tend to their health needs.

In a recent study, the New York-based Commonwealth Fund reported that about one-third of US patients hospitalized with heart failure in 2006 didn’t even receive written discharge instructions. And that is only one component of discharge planning.

Dena Salzberg, a Massachusetts patient advocate and care coordinator, has “gone head to head’’ with hospital case managers after receiving frantic calls from families who hire her to intervene. “They’re saying, ‘I’m so scared. They’re kicking my mother out of the hospital,’ ’’ says Salzberg, a nurse who runs Care Management Consultants. “People are leaving hospitals with a lot more complex needs.’’

So who are these uber-efficient hospital case managers? They are nurses, social workers, or even an embedded care manager of your insurance company, all operating against a backdrop of managed-care and Medicare mandates on length of stay. Their goal is simple: swift exit.

The results? Sometimes the discharge plan is unworkable. The case manager assigned to my father the day he was expected to go home apparently never bothered to find out he was incapable of walking up the steps to his house.

Other times, families or their hired guns - like patient-advocate Salzberg - are doing battle with case managers over post-hospital placement driven by moving patients out rather than forward.

And still other times, a patient is boomeranged back to the same hospital within days of an express-lane discharge. Eighteen percent of chronically ill people hospitalized in the United States were readmitted or went to an emergency room as a result of complications after a discharge, according to the Commonwealth Fund.

And as families race to their bedsides, or work the office phones to craft a care plan, the ripple effects are felt elsewhere in the economy: American businesses lose up to $33.6 billion a year because of employees’ caregiving responsibilities for someone age 18 or older, according to a 2006 study conducted by the MetLife Mature Market Institute and the National Alliance for Caregiving.

Of course, there are some outstanding, compassionate case managers. Let’s make sure they are not part of a dying breed. As the ailing US healthcare system once again lies on the national examination table, some elixirs go back to basics: more resources directed toward exceptionally coordinated continuity of care - as much a patient lifeline as the heart surgery she received in the operating room.

A high-quality and efficient care-delivery system also recognizes the public value of family caregivers in this process. With insurance cutbacks that narrowed reimbursable services, we are required to dispense post-hospital medical care previously unthinkable for anyone except a healthcare professional; by flushing feeding tubes and dressing amputees’ wounds, we help our loved ones remain at home and away from more costly alternatives. It’s all the more reason for gold-standard care coordination.

Discharge planning should not require paying an advocate to wage war, further dividing the rich from the poor in healthcare. And families should be part of a collaborative effort, not treated as though we are double-parked in a tow zone.

Deborah G. Schuss is a freelance journalist.