On Aug. 12, Anna Costa of Champion paid a visit to the hospital.
It was at that moment, say area hospital staff, that the plan for her discharge on Aug. 15 likely began.
"Really, they start discharge on day one," said George Semer, M.S.N., R.N., manager of the case management department at St. Joseph Health Center in Warren.
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Tribune Chronicle / Michelle Robbins
Pat Maher, R.N., gives Samantha Burkhimer of Warren discharge instructions as she prepares to take her newborn son, Bently, home on Friday at St. Joseph Health Center.
According to a study published in The New England Journal of Medicine and reported on in a recent New York Times article, one in five Medicare patients returns to the hospital within 30 days of being discharged.
Semer said that's where the health center strives to keep readmissions to a minimum - by identifying needs prior to a patient's departure.
Amy Smith, vice president of care management at Forum Health Trumbull Memorial Hospital, said the two most common causes of patient readmission are not adhering to instructions and having unrealistic expectations.
Fact Box
Make hospital discharge easy
George Semer of St. Joseph Health Center, Humility of Mary Health Partners, and Amy Smith of Forum Health offer the following tips for a smooth hospital discharge:
- Have advance directives available so caregivers know what the patient's wishes are at and after leaving the hospital. Communicate those wishes to the staff
- Keep the what-ifs in mind - what if the patient can't go home? What if the patient needs a higher level of care? Have they visited nursing homes?
- Know and have access to patient financial information, if necessary. Know if you are approved for Medicaid or other programs. Be aware of the long-term care policy.
- Know when to return to basic activity - when can you resume driving, sexual activity, return to work?
- Keep follow-up appointments and use the discharge checklist.
- Be realistic about what to expect after discharge.
- Be knowledgeable before you come into the hospital as to what your insurance covers. A rehab facility may not be covered, but not in a specific situation - it may not be what the patient believes it to be.
Costa, who was sent home with the same medications as she was taking before, seems to be following her instructions to the letter. She said hospital staff told her more of what not to do than what to do when she got home.
"They said take it easy, and that's what I did," she said.
Costa said she was told to take one of her pills on a different schedule, and the hospital also made a follow-up appointment, from which she got a good report.
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Also, she had been walking for an hour a day, and she's increasing her time little by little to work up to her former level.
Semer said a best-case scenario for a patient discharge would be to return to home, but that's not always what works best for the patient. Add-on services needed may include a rehabilitation facility, a nursing-home type setting, skilled nursing or skilled therapy at home. He said nurses and social workers talk to families and patients to learn what's available to each patient after the hospitalization.
"We have a screening tool that we use to see if a patient is a high-risk patient," Semer said. Factors on it include diagnosis, age and former visits to hospital.
After discharge from St. Joseph Health Center, there also is a follow-up call from a nursing staff discharge liaison, who checks safety concerns, takes questions about instructions patients have received, and if they felt the hospital met their needs.
Smith said patients may need add-on services or acute care as a bridge to getting back home.
"We have to look at each patient and the resources they have to work with and their home environment," she said.
Smith said case management and social workers work with the family to determine needs after their loved one leaves the hospital.
A case manager is a nurse that coordinates the overall care of the patient including the discharge plan. They provide written discharge instructions and prescriptions and make arrangements for durable medical equipment such as oxygen, a cane or a walker. Nurses may offer other educational materials related to the patient's condition, such as physical therapy or diabetes literature. Social work handles what a patient needs after discharge - such as Hillside rehabilitation - and is the part of the team that will work with the family to find out what facility they're interested in or prefer and connect them with other community resources that may benefit the patient.
Smith said since hospital stays are shorter these days, it's not always realistic to expect that at the time of hospital discharge, every patient will be back to their regular level of function, and many people do require acute care. The role of nursing homes has changed somewhat in turn.
"The nursing home is more often used as an intermediate stop back to home. The goal is to go home and be independent, but they may need physical therapy or administration of medications such as intravenous antibiotics," she said.
Both hospital representatives said there are tools to check the rate of readmission.
Smith said Forum Health has reports from different vendors that it uses for joint commission accreditation needs. Also there is a "hospital compare" option provided by Medicare on the Department of Health and Human Services website.
"We try to really focus on optimizing use of post-acute care services so when they leave they have a good idea of what they need," Smith said.
"We have the ability to identify the reason for the readmission, which may include the environment wasn't suitable for them to return to - maybe they need a higher level of care," Semer said.
He added that it is also determined if the visit is even related to the previous hospital stay or if perhaps it's caused by failure of the patient to obtain their medication.
Keeping track of such information can affect payment, he said.
"Different payers have different time limits - a week, a month, some are undefined," he said. "That's where we strive to keep readmission to a minimum, by identifying those needs prior to them leaving."
Smith said the hospital's informal rule of thumb is "to get the right patient at the right level of care at the right time."