Director’s desk: Focusing on the nitty-gritty

by Peggy Rossi, BSN, MPA, CCM

Having performed discharge planning for many, many years, I’ve learned one key component is now more true than ever: Assessments must be very comprehensive. We are dealing with a wider variety and different mix of patients. For example, we are seeing an older population that is living longer, often with dementia. These are patients with multiple comorbidities who are living on a limited income. We also are dealing with a larger group of patients—again, with multiple comorbidities—who are living longer due to medical advances and require costly medications and repeated readmissions for complications or procedures. Additionally, we care for the homeless, who are often riddled with mental health or drug addiction problems as well as comorbidities.

Although many patients now have insurance with low premiums, in many cases their insurance covers less than they expect, leading them to face unexpectedly high copayments and deductibles—or no coverage at all for specific services. Sometimes these patients choose to forgo services they can’t afford. In addition, homeless, mentally ill, or substance abuse patients frequently receive care only at local emergency departments. 

These patients’ postacute care needs are often as complicated as their hospitalizations. Caring for them may require multiple personnel, as well as determination: It may take a discharge planner hours to explore community resources for discharge, only to find providers that have long waiting lists or that are not staffed or equipped to properly care for a patient. There are other issues to overcome as well, such as locating resources for a patient and communicating with his or her family. Even if a physician deems a patient ready for discharge, the patient’s stay may be extended if resources cannot be located or if a public conservator is required. 

Due to these factors, hospitals are often faced with avoidable or variable days, all of which are low-hanging fruit for a denial from the insurer. Cases that extend past a planned discharge date may also affect a hospital’s length of stay metrics, daily census, and hospital throughput. If such a case involves a patient with limited income or high copayments and deductibles, hospitals must get creative about how the bill for ongoing or postacute care will be paid.   

With this in mind, it is imperative that case managers apply what I call a “nitty-gritty” approach to initial and ongoing assessments. During assessment, case managers must explore every detail of a case that is out of the norm. When possible, they should start their research and referrals as soon as needs are identified. This means as case managers review the medical record or interview the patient, family, and/or medical team, they should dig deep and ask the hard questions to ensure any unforeseen needs are addressed as early as possible. Case managers must not wait until right before a patient’s discharge to begin educating the patient and family on topics like the following:

• Providing information about alternate funding programs for which the patient may be eligible
• Teaching the patient or family about ongoing care needs
• Encouraging the family to explore skilled nursing facilities or board-and-care homes if a home plan is not feasible
• Making adaptations to the home to accommodate the equipment or supplies the patient may require if returning home after discharge—this may include tapping the services of fraternal or charity organizations

In addition to solving complex post-discharge problems, the nitty-gritty approach also helps identify the basics that are needed at discharge. It can assist in answering the following questions:

• Where and how will the patient receive care? Will it be from a home health agency, or can care be obtained from an outpatient facility?
• Where and how will the patient get needed medications?
• Will the patient have transportation to and from follow-up appointments?
• Does the patient have properly fitting durable medical equipment? Many patients are bariatric and require heavy-duty equipment.

Take assessments to the next level—dig deep and get to the nitty-gritty. In the long run, this approach helps establish correct linkage and prevent unnecessary readmissions. It can also result in a safer discharge and increased patient satisfaction.

Editor’s note: Rossi is a consulting associate for the Center for Case Management in Wellesley, Massachusetts. Opinions expressed are that of the author and do not represent HCPro or ACDIS.