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Discharge Starts Upon Admission

Over and over I hear “discharge planning starts upon admission”.  This is a mantra that has been pounded into me since the first day of my current position.  There is nothing more true than that phrase.  Truly effective discharge planning starts from the moment the patient enters the hospital.

In order to effectively build a working relationship with a patient and their family it is important to become a part of their treatment team as early as possible.  This can be as simple as a quick introduction upon admission and providing the patient and family your contact information to reach you with questions.  Doing this plants the seed of a working relationship. 

Once you have been introduced into the patient’s care, you become more than a discharge planner to them.  You are a resource, someone they look to for answers and ideas, and not just someone who comes to usher them out of the hospital.  As a case manager it is important to establish yourself as an independent professional to the patients and families, and not just someone filling orders. 

Once you establish a place in the treatment team, you can begin to nourish a trusting relationship with the patient and family.  Simple contact throughout their stay and remaining available to them is what will build this.  The doctor is busy and can be difficult to reach, but the case manager needs to remain easily attainable to fill this void and answer questions when the doctor cannot be reached immediately.  Being available to the patient and family is reassuring and comforting to them, and makes you reassuring and comfortable for them to work with.

Throughout building a relationship you have done a majority of your work just by simply getting to know the patient and family.  Using simple conversation you can gather a history and establish a patient’s needs and wants without a formal and dry interview.  This helps them remain comfortable and allows you to appear genuinely interested in the patient and where they are from. 

This background combined with knowing their current medical needs allows for the formulation of the patient’s discharge plan.  Which at this point should be simple to present to them and move rather quickly as you have built a trusting relationship through early and frequent contact with the patient and their family.  Discharge planning is truly 90% relationship building and 10% actual service arranging.  Once you get a family to trust you, the rest of the planning is simple. 

You should become the constant figure that helps make sense of the chaos throughout the patient’s stay.  You become the beacon that helps them realize there is an exit from the hospital that is safe and attainable for them.  This is all accomplished by starting the discharge planning upon admission and remaining constantly recognizable to the patient and family throughout their stay.

Providing Options

One of the most important things to remember in the hospital is that patients and their families need to feel they are in control of patient care.  The last thing they remain in control of is the ability to say yes or no to procedures and continuing care options.  It is important to not take this away from them, but it is also important to guide them through their decisions while keeping them as simple as possible.

In relation to discharge plans it is important to recognize the difference between choices and options.  Giving a patient choices is walking into the room and saying,  “The doctor says you need to go to a Skilled Nursing Facility (SNF) here’s a list let me know what you pick.”  Giving options is explaining to the patient why they need a SNF, what they will do there, and letting them know a few places close to their home.  Guiding them in making the decision, and helping to make it as simple as possible.

When working this way the patient retains their right to make their own decisions, however, as they may not know which direction to go in, as they are already in a crisis situation and unhappy about losing control of their life, we are assisting them by doing most of the work for them and allowing them to simply give their approval. 

Some may say this is not an appropriate way to work with patients, and that it is taking away options from them.  Let me explain how this is better by referring back to the SNF example above.  Imagine your mother is in the hospital and has to go to a SNF.   Your mother being sick already upsets you, and you are now more upset that the doctor has said she cannot return home.  I then walk into the room after the doctor and hand you a 3 page list of SNFs around the area and ask you to choose one.  In the already fragile state you are in that kind of decision would be unmanageable. 

What you need is guidance.  You need someone to help sift through your mom’s needs and your wants and make that list more manageable.  To simplify your decision and take away days of debate and searching that only transform a tough decision into an impossible one.  It is much easier to make a decision in hours than in days.  That is a burden that you do not need at this time.  You need to be with your mother and family. 

It is always important that a patient and their family be in control of their healthcare.  It is equally important that we, as healthcare providers, realize we are the ones who can help keep them in control of an unmanageable situation by providing them with easier decisions by simplifying their options.  Providing a more manageable situation for patients and their families is a key to quality case management, as well as the best service we can offer. 

Merry Case Managemas!

The Holiday Season clearly brings us all around to considering issues related to quality of life, so I figured this is as good a time as any to begin touching on this huge topic.  Quality of life should clearly be one of the driving factors in all decisions related to discharge planning, and is one of the few factors that can out weigh medical treatment in the hospital setting.

Let’s think about what is really important during the Holiday Season.  To me the most important thing during this time is time with my family and friends.  I would wager this would also be a popular view among our patients.  Which brings us to the dilemma at hand.  Is it better for the patient to impose continued in-patient care upon them, or to allow them the time at home with family and continue the care after the holidays?

I would argue that the job of the Case Manager is to allow for continued care to happen while allowing the patient to go home with their family.  To arrange a strong out patient follow-up plan and to explain in an unmistakable way the importance of this follow-up to the patient.  Also, to impart the needed understanding of the responsibility the patient and family have to ensure this follow-up happens, since we are allowing them to enjoy the higher quality of life they will have at home.

I think it is important to impart the idea that “we are allowing” the patients and their families to enjoy this time together.  Imposing this idea into their thought process instills that the time with family is a reward of compliance with their treatment plan.  This will create a higher rate of compliance and build a working relationship between the patients and the medical professionals. 

On the Case Manager’s side of this it is important to consider that time with family, friends, and all quality of life issues are important parts of a patient’s treatment plan.  For most patients it is the most important part of their plan.  We are the mediators between the patients and the Doctors that can build a treatment plan for the patient that allows them a higher quality of life.  We can get patients home to their families and allow Doctors the ability to discharge them and get home to their families.

In the end it comes down to the idea that medicine is worthless without a meaningful quality of life to go along with it.  Case Managers are the people that can marry these two things.  So, in turn, I would like to wish you all a Merry Case Managemas! 

Putting Medical into Social Work

From here forward I am going to use the term Case Manager purposefully interchangeable with and replacing the term Social Worker.  Since I will be doing this I thought I should explain why I feel this is appropriate in my perspective of how a Social Worker/ Case Manager should function in the hospital setting. 

Social Workers need to be more fluent with the clinical side of cases and Nurse Case Managers should also be more fluent with the social aspects of cases.  I want to focus on the need for Social Workers to increase their clinical knowledge and be more involved with the medical aspect of cases.  I feel it is imperative for this to happen for Social Workers to remain relevant in the hospital setting.

For patient care to be efficient and effective in the hospital their needs to be an open line of communication with all parties involved.  For this to happen all parties involved in the patient’s care need to have a working knowledge of all aspects involved in the case.  In order for a Social Worker to be effective they must have a strong base of medical knowledge before they can make a plan for the patient’s discharge. 

This knowledge needs to go beyond simply knowing what a diagnosis means.  An effective Social Worker needs to be able to recognize the progress of a patient throughout their treatment in the hospital, and anticipate where the patient is at in their care and when they are able to continue their care as an outpatient.  Also they should be able to proactively formulate ideas for different paths of care and discuss these with the physician and nurse.  Only with this knowledge will relationships be able to form with the physicians and nurses that will allow for proactive discharge planning and seamless patient care.

If a Social Worker is unable to answer any medical questions for a patient or their family and can only refer them to the doctor or nurse then their function is no different than the Medical Equipment delivery person.  When they begin to be able to answer some simple medical questions for patients and families they become part of the treatment team.  They also begin to build a stronger level of trust with the patient and family that move them beyond being a valet for discharge.

Once the Social Worker can function in that fashion it opens up discussions with the physicians that begin to build a trusting relationship.  This allows the Social Worker to bring ideas for discharge to the physician, and allows a two-way dialogue to begin.  This is the point proactive discharge planning can begin, and truly when the Social Worker becomes involved in patient care.

This Case Management approach by the Social Worker paints them as a Medical Professional and not a Human Services worker to the patients and their families.  It keeps the focus with the families on medical needs and guides them away from social needs unrelated to the patient’s medical care.  Not to take away from the importance of those other needs, but they should be dealt with on an outpatient basis and the focus in the hospital should remain on the medical issues presented and arrangements for the care of those issues.

Once this focus is achieved I find that the term Medical Case Manager can easily replace Social Worker without any problem.  In fact it seems to be more fitting and focused for the position.  With the direction healthcare is moving in it is going to become increasingly important for Social Workers to become more medically relevant.  I don’t think it is too far fetched to say eventually these 2 positions will become one.   Without increasing the medical knowledge Social Workers have, they may begin to lose their place in the hospital to nurses and a hand full of visits by Social Workers from outside agencies.

Hello and welcome.

Over the past 6 years I have gained a passion for Medical Case Management and Social Work in the Hospital setting.  It is a high stress, fast paced, and rewarding field to work in.  I have had the opportunity to connect with many amazing Nurses, Therapists (physical, occupational, respiratory, etc.), Doctors, Social Workers, Administrators, financial counselors, and certainly patients and their families.  One of the most important things I have learned through this is that together we have to work toward a common goal or none of us will be successful in our particular jobs.

In the position of Case Manager I have had the privilege of being the person that assists in putting the pieces together from all disciplines to make a meaningful, effective, and manageable treatment plan for the patients and their families.  Balancing treatments, insurance and affordability, access to care, and safe discharge planning has been challenging as well as rewarding.  It has allowed me to excel while also accessing the best others have to offer as they push me to be better. 

Self reflection aside, what I have learned throughout this time is the many ways we can improve access to care for patients outside of the hospital setting, maximizing quality care in the hospital, and expediting that care to allow patients to get home to their families or simply to get out of the hospital and away from the health risks that persist there.  Moving healthcare out of the inpatient setting and allowing patients the access to care on an outpatient basis, in my perspective, is what we should strive for in medical case management.   Also in doing this we must educate and empower patients to take control of their healthcare and provide them with a treatment plan to do so.

My goal with this blog is to create an open forum to discuss the many different topics that relate to Medical Case Management.  By doing so, I hope to inspire and be inspired to help Case Management progress to meet the needs of patients and the Health Care Industry in this modern world.  I believe there is a lack of passion and inspiration in my field currently, and I want to help create that passion and creativity.