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

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