Now, patients in acute care hospitals are much sicker than before- as most patients have multiple co-morbidities contributing to and complicating the cause for admission.  Treatments are more complicated.  And patients often complete their treatment regimen (such as their course of iv antibiotics) either at home or in a skilled nursing facility.   So patients being discharged from the hospital are sicker than before and require more complicated care after discharge.

Home life is different today as well.  Nowadays, the majority of adults in each household must work, making home caregiving more of a challenge.  Determining and then meeting patient’s needs after hospital discharge is more of a challenge.

Plus, there’s another factor.  Hospitals are under pressure to prevent readmissions.  Not just because that’s a good thing to do, which it is, but due to financial reasons.  Hospitals may not get reimbursed for care if a patient has an avoidable readmission soon after discharge.  This incentivizes hospitals to optimize coordination between inpatient and outpatient care (although I’m not sure how it’s the hospital’s fault if a patient doesn’t make it to their outpatient f/u appointment and end up readmitted- but that’s medicine today).

Add all of this together and you get our current hospital environment with multiple layers of people involved in discharge planning.  It’s really taken on a life all its own.  There are social workers, case managers, transitional care managers, nurse navigators, and patient experience services added to the mix of medical providers who interact with patients/families during hospitalization.  While everyone shares the goal of optimizing patient outcomes and preventing avoidable readmissions, they each live in their own silo- with their own priorities and metrics that need to be met.

The desire to discharge patients as soon as medically stable has led to the belief that discharge planning starts upon admission.  This is not unreasonable because it can take time to get everything in place for a safe discharge.  However, this timeline can present challenges when all of the silos are in action while the patient’s outcome is still uncertain.

Mrs T, 78yrs old, had been active and independent her entire life.  Now she is in the icu after  suffering a massive myocardial infarction the day before.  Mrs T is intubated, her kidneys have shut down and despite being on powerful cardiac medications,  her heart continues to fail.  She is dying.  I met with her family shortly after her arrival to the ICU, and while devastated, they understand her condition.  Once her out-of-town son arrives later tonight, she will be transitioned to comfort focused care.  And sadly, we expect that she will die soon thereafter.

When I checked back into the ICU,  a case manager was talking with one of Mrs T’s daughters in the hallway.  I listened in on the discussion.  The case manager was asking multiple questions to help guide discharge planning: did Mrs T live alone, did she require any assist devices, did she need help getting to doctor appts?  Her daughter was patiently answering these nonsensical questions with a pained look on her face.  I gently interrupted the discussion and pulled the case manager away and explained Mrs T’s reality.  The case manager was apologetic; she had 10 new patient admissions to see along with her ongoing patient load so she had not reviewed Mrs T’s chart before reaching out to family.  She wasn’t aware that Mrs T was likely going to die during this hospitalization, and as such, her family did not need discharge planning assistance.

I’d like to say that this was the only time I’ve witnessed this type of interaction- but it’s not.

What does it say to a family when the medical team is telling them that their mother is dying, while the discharge planning team is preparing for her eventual discharge?