Failure in discharge planning

Elizabeth Newman
Elizabeth Newman

There's a feel-good national story that debuted last week around how emergency responders helped an 81-year-old man.

As reported by various media outlets, the Army veteran had been in a “hospital and rehabilitation center” for treatment of cancer. When Clarence Blackmon returned home, he had no food and no family nearby. He called 911 because he was hungry.

Of course it's wonderful the dispatchers showed up with groceries, and the dispatcher who stuck around to make him some ham sandwiches gets an A-plus. A local church is looking to help, according to the Huffington Post, and Blackmon said he is getting a home health nurse.

But what a failure of discharge planning.

I say this not to pick on the unnamed facility or the discharge planner, but because there are more Clarence Blackmons that we realize who are leaving skilled nursing facilities with no ability to care for themselves. In a 2013 report from the Office of the Inspector General, the authors wrote, “For 31 percent of stays, SNFs did not meet discharge planning requirements.” The OIG recommended surveyors “ increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable.”

I know everyone loves to complain about surveyors, and they are often right. But in this case, if Blackmon had not asked for help, he easily could have fallen from hunger and broken a hip. Or his continued malnutrition could have worsened his other medical problems. The bottom line is many of these scenarios, when multiplied by dozens of patients leaving hospitals, rehab centers or SNFs, end up costing the healthcare system far more money than hiring a patient navigator, care transitions nurse or additional discharge manager.

When I worked for a hospital system, one of the best things I saw was the creation of a patient-navigator program for oncology patients. I had thought this was a program that involved navigators chatting with physicians about care plans, and there is a little of that. But far more time is dedicated to the patient's daily needs.

When I shadowed one for a day, she told me about an underweight patient who needed Ensure. The problem was if she had a case of the nutritional product delivered, it would be stolen. She instead had to track down a case that was light enough for him to carry on the bus, but would help him get through the week. Then she moved on to helping find a home for the dogs of a terminally ill patient. Other expert guidance can be found in McKnight's multi-part series about care transitions, written by Align's Neil Gulsvig.

The bottom line is we know some residents have circles of support and family members ready to jump in to serve basic needs. But we need more employees and systems in place to catch people like Blackmon before they go hungry.

Elizabeth Leis Newman is Senior Editor at McKnight's Long-Term Care News. Follow her @TigerELN.





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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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