Hello, and a very happy National Case Management Week to all of you!
Every case manager out there, nurse or social worker, has had to deal with a difficult discharge or two along their paths. Some days I think I could write a book about these cases, because honestly, you cannot make this stuff up!
There are two kinds of difficult discharges: medically fragile patients who are hard to place due to their complexity, and then what most of us know as social admissions.
Let’s tackle both: medically fragile patients are not easy to place, especially since most never appear stable enough to get to a least restrictive clinically appropriate next site of care. Many times we need to think about what will happen down the road for these patients and make sure we have had the appropriate goals of care discussions.
Sometimes you may think that such discussions will help us from kicking the can down the road, but honestly, when given an option to families, most are not in the medical field and just simply do not understand what “do everything” means. One of the more recent experiences we have had in attempting to combat this was actually a great campaign about patient wishes. Having those conversations before there is an emergency is the single most effective strategy there is. Because after all, the emergency room is just that – for an emergency, meaning no one planned to be there, and this sends minimally functioning families into dysfunction.
Now, let’s move on to the social admissions. I am not speaking about behavioral health here; those patients could be a whole other article!
Almost all of the social admissions we have seen were cases where patients were put in a bed because the emergency department (ED) is not equipped to handle the situation. We cannot blame the ED for this; they are the department that should be used to rescue emergent situations. They are not the department that should have to deal with social issues.
So, what can they do? They can try to find even a glimmer of a medical issue so that they can place the patient in a bed up on the unit. And then the clock starts ticking, the doctor is coming and will want the patient out!
My heart breaks for these patients, as do most hearts in case management. But the fact of the matter is: we cannot put these patients in a hospital bed! The beds need to be kept for those who need medical attention. So, what’s an ED to do? This is where I cannot advocate enough for social work in the ED and community health workers in the field.
They know their resources and are so resilient in creating a plan for these high-risk patients. And of course, each hospital really needs to work with its advocacy groups to get better community services out in the community to “catch” these patients.
I also want us to be very careful: many times the doctors in the ED and nurses are quick to say “social” admits. But please make sure that the caregivers truly listen to the family that brings in the so-called social admit.
Even a very minor urinary tract infection (UTI) can turn an elder’s life upside down! Some questions to consider: What happens when the family just drops grandma off and ghosts the hospital? All the while, we know that the family is spending her money!
Also, how do you suggest the case management teams get more involved at the state and national level, to advocate for these patients being affected?
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