DISCHARGE
PLANNING
Bill Lyons, MD
BACKGROUND
• Surging interest from professional
societies, payers, Joint Commission
• Among reasons for the challenge
– Aging, increasingly complex population
– More, and more specialized, venues
– Providers defining practice by location
CASE 1
• Mrs. G, a 96-year-old woman is seen by
her physician at a home visit
• Progressive shortness of breath over 2-3
day period
• No fever, chills, cough, chest pain
• Was discharged from hospital one week
before
CASE 2
• 68 yo man transferred from acute hospital
to distant suburban SNF after uneventful
valve replacement
• On warfarin + enoxaparin until INR 2.5-3.5
• Progressively less ambulatory
• INR rises to 17, even after warfarin held
and vitamin K administered
• Cardiac arrest
“BOUNCEBACKS”
FACTORS ASSOCIATED WITH
POOR DISCHARGE OUTCOMES
• Age>80
• Fair-to-poor selfrating of health
• Recent and frequent
hospitalizations
• Inadequate social
support
• Multiple, active
chronic health
problems
• Depression history
• Chronic disability and
functional impairment
• History of
nonadherence to
therapeutic regimen
• Lack of documented
patient/family
education
INFORMATION TRANSFER
INFORMATION TRANSFER
• Discharge summary not for Med Records
• Discharge diagnoses should include:
functional, cognitive, behavioral, affective
• Discharge instructions must include red
flags, and whom to call
• Explicitly list follow-up studies, appts
INFO TRANSFER, cont.
• Functional status: baseline, transfer
• The Big Picture
– Global goals of care
– Preferred intensity of care
– Advance directives
MEDICATIONS
•
•
•
•
Reconciliation = (New List) – (Old List)
Tapering and stop schedules
Document drug indications
Target symptoms for psychiatric drugs
OTHER PEARLS
•
•
•
•
Early involvement of PT and SW
“Dispo” daily in thought, speech, prose
Discuss discharge by goals, not schedule
Avoid discharge to SNF or home with HHC
on weekends
• Involve primary care provider
• Involve clinical pharmacist
PLACES PATIENTS GO
POSSIBLE DISCHARGE
LOCATIONS
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•
•
•
•
•
•
Home with family support
Home with HHC
SNF
Nursing home, ALF, custodial care
Acute rehab
LTAC
Hospice
HOME WITH
HOME HEALTH CARE
• Medicare qualifiers
– Reasonable and necessary
– Skilled services (RN, PT, or ST) needed
– If above needed, can bring in OT, SW, HHA
– Home bound: Leaving home is infrequent,
• …requires great, taxing effort
• …requires supportive devices, transportation, help
of others
• …medically contraindicated
HOME HEALTH CARE
FINANCING
• Medicare A: RN, PT, OT, ST, HHA
• Medicare B: MD home visits, DME, labs –
but with 20% co-payment
• Homemaker services: no Medicare or
Medicaid coverage
SKILLED NURSING FACILITIES
• Patient requires skilled care: IV therapy,
artificial nutrition and hydration, complex
wound care, ostomy care, rehab
• Medicare pays 100% for first 20 days, then
80% for remaining 80 days
• Coverage stops when goals met or patient
stops improving
• Infrequent provider visits (~monthly)
ACUTE REHAB HOSPITAL
• Medicare criteria:
– Close medical supervision by physiatrist
– Needs 24h rehab nursing care
– Multidisciplinary needs, coordinated program
– Reasonable expectation of gain
– Able to participate in 3 hr/d of intense therapy
• Typical patients: head/spine injuries,
youngish-old after stroke
LONG-TERM ACUTE CARE
(LTAC)
• For complex, potentially unstable patients
requiring ongoing hospital-level care
• Specialty Select in Omaha
• Chronic ventilator patients, multiple IV
medications, extensive wound care, TPN
• Medicare qualifiers
– Frequent physician monitoring
– Need for highly-skilled care
– Expected LOS 25+ days
NURSING HOME (CUSTODIAL)
• Home with HHC < Care Needs < SNF
• Medicare does NOT cover
• Financing via private pay, Medicaid, longterm care insurance
CASE 1 FOLLOW-UP
• Hospitalization had been for viral
gastroenteritis
• Furosemide held during hospitalization
• Not resumed (or mentioned) at discharge
• Result: pulmonary edema
CASE 2 FOLLOW-UP
• Autopsy: 1500 mL grossly bloody fluid in
pericardium, hepatic congestion
• Positive feedback loop initiated
• No communication between SNF MD and
CT Surgery re significance of climbing INR
values