Discharge planning

Discharge planning is the complex collaborative process by which patients are discharged from hospitals to their homes with an array of home health care services or to an institution (health-related, skilled nursing, or hospice). In the acute care setting most patients return home with minimum difficulty, since their condition is usually transitory or episodic (minor surgeries, orthopedic problems, gastrointestinal disorders). With supportive families, the patient's return should be relatively uncomplicated.

The situations of those patients who require considerable care upon discharge, however, become complicated. Every rehabilitation patient has some kind of discharge problem. If a wheelchair is required, for example, the living quarters must permit passage of a wheelchair. Obviously a patient living alone will have problems if his home care needs (such as wound dressing) require the services of another person. Even when there are family members, their availability is not guaranteed, because the spouse may be employed and the elderly spouse may be too fragile to lift a heavy patient or push a wheelchair. The need for a nursing home or some other specialized program requires immediate attention to financing, transportation, special equipment, and the avail-ability of needed resources. With a shortage of nursing homes and mandatory state health department regulations, planning can take a long time and become an involved process. New York University Medical Center has addressed this problem over a period of time and has developed a model discharge planning unit (DPU) by which all complex placement problems are routed through their range of services by the social worker involved with the case.4

Since the Director of Social Service at New York University Medical Center was assigned the title Coordinator of Discharge Planning (as mandated by Professional Standards Review Organization legislation), the DPU is placed within the Social Service Department and because of its high priority, complexity, and impact on hospital planning. It is administered by the Assistant Director of Social Service. The unit consists of an MSW social worker, a BSW social worker, two registered nurses, and a clerk. These functions are combined with those of a transportation coordinator, an equipment coordinator, and a medicaid representative. To plan for complex discharges, all personnel must cooperate to ensure timeliness, financial eligibility, necessary equipment, method of transportation, and other essential factors. In reviewing the recent and pending legislation of the New York State Hospital Association in March" 1987, we listed the implications for social service and-the DPU. Some of the recently devised forms include a PRI (patient review instrument) to be requested by the social worker and prepared by the nurse in the DPU. This will require an evaluation of the patient's condition and care needs at time of discharge: ability to feed self, mobility,' extra care needs, additional equipment, and so on. (Patients requiring respirator help, for example, are extremely complex cases, since the average nursing home cannot monitor such specialized care.)

Documentation becomes the most critical aspect of this planning. Reimbursement rates depend on the level of care required and the demonstrated documentation of efforts at discharge. This is predicated on patient reaching ALOC (alternate level of care status), which means the patient is ready to go to another facility. Other problems of implementation occur: patients must be ready and informed; families who must be involved often "disappear" or conceal or transfer assets; patients with psychiatric or substance abuse problems are difficult to place; patients' rights must be observed. These are only a few of the possible problems in discharge encountered by the social worker and the discharge planning unit.

Admissions must be considered in this discussion, since discharge planning should begin even before admission. For example, we know an elderly woman coming in for hip replacement must have some assistance when returning home. Since this is an elective admission, arrangements for after-hospital care should be made before the inpatient surgery. Correct information at the point of entry in the system is vitally important such as details of insurance coverage, amount of time, and so on. Family cooperation should be stressed and encouraged, since their cooperation, especially at time of discharge, is particularly critical for rehabilitation patients. As much psychosocial information as possible not only enables the team to "plan treatment but also lo arrange an effective and appropriate discharge.