Eight Steps for Better Hospital Outcomes

By Harry S. Margolis 

  It’s become a cliche that hospital patients are being discharged quicker and sicker.  This has to do in large part with insurance, Medicare and Medicaid reimbursement systems that often pay hospitals a fixed amount per patient stay, depending on the diagnosis and treatment plan, no matter how long the patient stays.  Hospitals make more money by opening up the patient’s bed sooner rather than later for a new patient and a new payment.

    This situation is not necessarily bad for patients.  Often patients are happier and receive more appropriate care at home, in rehabilitation hospitals or in skilled nursing facilities.  Hospitals also have a growing reputation of harboring infections that can make patients sicker, so getting out sooner can help reduce the risk of infection.

    The goal of patients, their families, and hospitals is for the patient to move to the right place at the right time.  If everyone agreed about what the right time and right place were, hospital discharges would always run smoothly.  There can be a lot of reasons they disagree, whether due to the patient’s health status, the availability of care in an appropriate setting, or the family’s need for time to set up care at home.

    Whether there is a disagreement or not, patients and their families should know what steps they can take for a better discharge process.  Some of these must begin as soon as the relative is hospitalized (or before if the treatment is planned in advance rather than in an emergency).

    1.    Designate one person as the primary medical contact.  While there may be many family members looking in on the relative in the hospital, it’s important that all the information they receive from nurses, doctors and other medical personnel be forwarded to a single individual so that he or she can have the full picture.  Usually, this person will have been designated in advance in the patient’s health care proxy, but not always.

    2.    Take notes.  Whether you are the designated health care contact or another family member, you need to take notes on any medical information your receive about the patient, especially from physicians.  This will be an aid to memory, help in communication among family members, and even assist the physicians themselves who may not communicate as much as one would hope.  One way to make this happen is to leave a spiral notebook on the patient’s bedside table that everyone can add to.  Family members should be counseled always to include the date and time, the name of the person from whom they received information, and their own name.

    3.    Have a meeting.  One effective way to get all of the care providers talking to one another and focusing on your family members is to schedule a meeting with everyone involved.  This way, everyone will hear from everyone else and you will be able to come up with an integrated plan of treatment.  Again, take notes.  And if you are not sure that you understand something, ask for it to be explained again.  Or tell the group your understanding to see if it’s right.

    4.    Work with your social worker.  The hospital will likely assign a social worker or “discharge planner” to help coordinate communication in the hospital and set up a plan of care after the hospitalization.  He or she serves two masters, the patient and the hospital.  The social worker’s job is to help with both the in-hospital care and the transition out of the facility, to make both experiences as good and smooth as possible.  But in facilitating the transition from the hospital, the social worker has the secondary goal of making this happen as quickly as possible so that the hospital can begin taking care of another patient.  Family members may feel pressure to begin looking at transition facilities, such as rehabilitation hospitals or skilled nursing facilities, before they are ready or when they have no time available to do so.  Usually, if family members work with the discharge planner they can work out an agreement on what facilities are appropriate to check out or what steps need to be taken to set up the patient’s home for care.

    5.    Begin planning early.  Everyone who enters a hospital will leave and have to go somewhere.  The sooner you start planning for the discharge, the more time you will have to choose the appropriate placement or make the necessary arrangements at home.  Of course, this can be difficult given the other demands on your time – especially when you need to spend time with your loved one in the hospital – and the uncertainty often surrounding the patient’s recovery, which can mean that family members may not know for sure until the last minute what type of placement is appropriate.  But at least begin discussing this with the hospital social worker and family members at an early stage, so that you will know the options available and can move more quickly when the time comes.

    6.    Know your rights.  A hospital cannot force you to leave before you are ready.  However, Medicare or another insurer can stop coverage, forcing the patient to pay privately for the care, which can costs thousands of dollars a day.  Fortunately, both Medicare and state law provide certain protections against premature discharge.  Under Medicare, if a hospital determines that a patient no longer needs to stay, it must provide written notice that the coverage will end at least two days in advance.  The patient may appeal this determination through the local Quality Improvement Organization (QIO), the contact information for which is provided on the notice the hospital provides.  If the patient, or her representative, files the appeal with the QIO by noon on the day following its receipt, coverage will continue while the QIO is reviewing the appeal.  This usually buys the patient (and her family) at least a day or two of additional coverage, which may be crucial in terms of finding an appropriate placement or setting up care at home.

        In addition to Medicare protections, Massachusetts law also requires hospitals to provide a written discharge plan at least 24 hours before discharge, containing information about what after care services are needed and what has been arranged, as well as a list of necessary medications and a schedule for follow-up medical visits.  Medicare patients must also either sign the discharge plan indicating that they have received and understand it.  If they don’t agree with it, they can appeal it to the state’s Department of Public Health Advocacy Office, contact information for which must appear on the plan.  As with the QIO review, if the patient or her representative appeals to the DPH Advocacy Office by noon the day after receiving the discharge plan, the hospital cannot charge the patient for care provided while the DPH is conducting its review.

        The Medicare Advocacy Project of Massachusetts Legal Services provides a comprehensive downloadable description of discharge protections available here

        7.    But don’t stay too long.  While the comments above provide information that will help both in getting the proper care for your loved one and in delaying a rushed discharge, there’s no reason to extend a hospital stay beyond what’s necessary.  Hospitals carry germs and can be noisy, interfering with necessary rest following an illness or surgery. Most people would prefer to be in their own homes.  And if they require continuing physical or occupational therapy, that can often be better provided in a skilled nursing facility or rehabilitation hospital.  The goal needs to be the best care in the best place for the patient.  It may take some time to choose the best place for continuing care or to make the arrangements at home, but the process should move along with all due speed so as not to unnecessarily extend a hospital stay.

    8.    Get help if necessary.  Patients who don’t have family members or friends to be their representatives and advocates, or family members who feel that they need help in the process, can hire professionals to assist them.  Many geriatric care managers fill this role and a new profession of health care advocates, who are often nurses or physicians, is becoming established.  Their help can be invaluable.

    No one wants to spend time in a hospital since it means that their body is failing them in some way.  The hospitalization may be planned in advance for a surgical intervention or be an emergency as the result of an injury or illness.  In either case, patients and their family members or other representatives need to be active to make certain that they get the best possible care both in the hospital and afterwards.  Following the steps outlined above can help achieve these goals.

    The Center for Medicare & Medicaid Services provides a guide and checklist for discharge planning that can be printed out is available here.  

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