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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.