Most sizable hospitals now employ social workers, whose primary duty is coordinating patient moves from one level of care to another. The transitions, arranged with the patients and their families, are generally from the hospital to the home, rehabilitation facility or nursing home. Patients who benefit from a discharge plan are 65 years of age or older, take seven or more medications daily, or have no support for care at home.
Social Workers Entrusted with the Discharge Process
Nurses or the hospital administration staff can process a discharge, but since most hospital social workers hold a master's degree in social work (MSW) and have knowledge of and experience dealing with local resources that might assist the patient, their advice and advocacy is sought. Successful discharge planning depends on all of these employees, as well as the attending physician, working as a team. The goal is to improve the current rate of almost 20 percent of Medicare patients being readmitted to the hospital within 30 days of discharge, as reported by the U.S. government's Agency for Healthcare Research and Quality. To begin, the social worker assesses what functions the patient needs help with, the support available at home, and the patient's mental and emotional states.
The Basics of a Discharge Plan
Medicare requires certified hospitals to identify and evaluate patients who may need discharge planning assistance. The evaluation should be done in a timely manner and address the need for services following the hospital stay and availability of the services. Then the evaluation results must be discussed with the patient, and the patient's family, if possible. The evaluating social worker may make recommendations on medications and diet; medical equipment needed; who will handle meal preparation, chores and transportation; training for the caregiver; and possible referrals to home care services.
Social Worker Intervention
If a patient's family member needs help in arranging home care or finding a nursing home for the patient, the discharge planner should provide a list of and information about local choices. The social worker may contact the facilities to determine which have vacancies. Once the family decides on a home or service, the social worker should follow up to provide those taking over care with needed medical data and discharge information.
Follow-up After Discharge
Hospitals in Pursuit of Excellence (HPOE) reported that a case study done in Chicago's Rush University Medical Center shows that post-discharge telephone calls from the center's social workers have reduced readmissions, improved patient satisfaction and eased the burden on caregivers. Within 48 hours of discharge, the first call is placed. The average number of calls per person to resolve the problems they were experiencing is 3.49. Patients reportedly loved being called; it made them feel that someone cared about them and that they were respected.
Improving the Process
Because discharge/transition planning does not generate income for a hospital, it often is not given the attention it needs. Those involved in this end of health care would like to see these improvements: more training and counseling for families and other unpaid caregivers; improved communication between the hospital and community-based services; and development of better educational materials, in multiple languages, to help patients understand the types of assistance that might be available to them and how to navigate care systems.
- Photo Credit patient image by JASON WINTER from Fotolia.com
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