Discharge planning, social work, and legal concerns Flashcards
What are the two most important things to consider in determining if a patient can be discharged in terms of general safety?
- Functional capacity (ADLs)
- Living situation
List the major locations to which a patient can be discharged.
Home
Shelter
Outpatient rehab
Inpatient rehab
Nursing home
LTAC facility
When a patient is discharged home, what are some possible services that may be provided?
- Outpatient PT/OT
- DME
- Home Health
- Hospice
What services can be provided for patients with Home Health?
- Medication administration (RNs, PCTs)
- Wound care (RNs, MAs)
- PT/OT
- IV care (<3 infusions per day)
What must be ordered to see if a hospital patient qualifies for Home Health and to set up the services for discharge?
A case management consult
A patient in fairly good health who has nowhere to go can be discharged to where?
- The street
- A shelter
(per the patient’s preference)
True/False.
In the inpatient setting, it is our responsibility to prepare safe, optimized discharges for patients, but it is not our responsibility to take care of every little detail and “coddle” the patients.
True.
It is acceptable to give patients some responsibility in setting up outpatient follow-up, securing their medications, etc.
But if you have time and energy or expect the patient will fail, it is better to provide more assistance.
True/False.
The advent of quality control and national standards has made most shelters and nursing homes into high-quality, fairly comparable locations.
False.
They are highly variable in quality.
For any stable, hospitalized patient with significant substance abuse issues, what can be offered upon discharge?
Rehabilitation services
(inpatient or outpatient)
When does a patient qualify for admission to a nursing home?
When they cannot perform their ADLs alone or with the assistance of family/friends
When discharging a patient to a nursing home, what are the two broad classifications of care available?
- Custodial
- SNF
What care is provided in a custodial nursing home setting?
And a SNF setting?
Custodial: assistance in meeting ADLs
SNF: similar to Home Health needs
How much rehabilitation is typically offered in a nursing home providing SNF care?
~2 hours/day
True/False.
Both custodial and SNF care are both typically covered by insurance in the nursing home setting.
False.
Custodial typically is not.
SNF typically is.
True/False.
If a nursing home patient needs frequent IV antibiotics, then they should be discharged to SNF care.
False.
These patients should go to an LTAC facility.
Patients with what indications should be discharged to an LTAC facility?
- Frequent antibiotics
- Ostomy care
- Assisted ventilation
- Etc.
A post-stroke patient needs intense rehabilitation. Where should they be sent?
Inpatient rehabilitation (IPR)
What is the general indication for discharge to inpatient rehabilitation?
Aggressive care for 1-2 weeks to help patients recover their ADLs
- Patients post-CVA, post-trauma, with critical illness myopathy, etc.
What quantity of therapy is provided in inpatient rehabilitation per day?
~3 hours / day
True/False.
Inpatient rehabilitation services are often provided within hospitals and by PM&R physicians.
True.
When a hospitalized patient has decided to go to hospice, what are the three likely locations to which they may be sent (and what are the prognosis requirements)?
- Home with hospice (<6-month prognosis)
- Nursing home with hospice (<6-month prognosis)
- Inpatient hospice (<1-week prognosis)
If discharging a patient who requires close follow-up, how can a provider help ensure that appropriate follow-up will occur?
- Set up the appointment before the patient leaves
- Recruit family and/or friends to help as indicated
- Send the outpatient provider a discharge summary and/or send it with the patient
When discharging a patient who is elderly, has low health literacy, has a complicated medication regimen, has poor medication compliance, and/or has poor eyesight, etc., what are some techniques that a provider can use to help increase the odds of proper medication adherence?
- Use closed-loop communication (have them teach back)
- Write down medications with a simple, clear format
- Simplify medication list as possible
- Use the USP pictograms
- Set up Home Health
- Engage family and/or friends to assist
Prior to discharge, what can providers do to help a hospitalized indigent and/or uninsured patient to avoid hefty medical bills and pharmacy costs?
- Consult social work for insurance set-up
- Educate patient about GoodRx
- Research local discount pharmacies
List some options that exist for aiding patients without access to transportation.
- Televists
- Some insurance companies (especially the public ones) send vans
- Sometimes, specific illnesses receive transport (e.g., dialysis patients)
- Some ride-share apps help with this barrier via services for patients such as pick-up/drop-off, medication pick-up, etc.
Are any options available for helping patients who do not have access to a phone?
Some free options via CMS with minutes and data
What should a provider do if a patient wants to leave the hospital AMA?
- Assess capacity
- Explain the risks and benefits of leaving
- Have the patient sign an AMA form (a liability waiver)
- Discharge them AMA
Should a provider let a patient without capacity leave AMA?
No.
What should an ED provider do if a patient expresses homicidal or suicidal ideation and needs to be kept in the ED?
Sign a PEC
(physician emergency certificate)
What form can a physician use to involuntarily commit a patient? How long does it last?
How does the physician then increase the amount of time if needed?
A PEC, 72 hours
→ a coroner must use a CEC (<14 days?);
→ a judge must issue a JC
True/False.
If a patient indicates homicidal intent against a specific person, a provider can PEC the patient but cannot break the patient’s confidentiality.
False.
The Tarasoff decision sets precedent for physicians to warn at-risk parties.
What set of laws frees bystanders from liability in providing emergency aid to individuals in non-healthcare settings (e.g., at a car accident)?
What stipulation applies?
Good-Samaritan laws;
the care must be reasonable
Via what two methods can an email sent from Outlook by encrypted to protect PHI?
- Type “ENCRYPT,” “SECURE,” or “SAFEMAIL” into the subject line
- Mark the email as “Low Importance”
For a hosptialist, what is the most effective way to ensure a patient’s PCP is aware of any high-risk needs when the patient returns to ambulatory care?
Closed loop communication
Typically through a phone call or email.
What information should be communicated in multi-disciplinary rounds with social work, case management, etc.?
- One-liner on the patient
- Anticipated time to discharge
- Barriers to discharge
- Any social needs
What PT scoring system has been shown to have a very high accuracy for predicting a patient’s likely discharge location as early as the day of admission to the hospital?
AMPAC
94% accuracy on admission in determining home v. SAR v. IPR v. LTC.
True/False.
The AMPAC scoring system has about a ~50% accuracy in predicting a patient’s discharge location on the day of admission to the hospital.
False.
The AMPAC scoring system has a 94% accuracy in predicting a patient’s discharge location on the day of admission to the hospital.
Which patients might qualify for home health services?
Those who are homebound with required skilled needs*
E.g., nursing, aides, PT, OT, speech, SW, medication management, wound care, etc.
Which patients might qualify for SNF care?
Those with any of the following needs ≥5 days per week:
* IV antibiotics
* tube feeds
* wound care
* intensive PT/OT
- What is the SNF RN:patient ratio?
- And the number of hours an RN is available?
- And the timeframe within an H&P must be written by a physician after patient arrival?
- 20-50:1
- 8*
- 72 hours
*LPNs should be available 24/7.
True/False.
Getting PRN medications at a SNF can be extremely difficult.
True.
Patients with what features are at highest risk for doing poorly after admission to SNF?
- Frequent falls
- Delirium
- Need for daily labs
- Poorly controlled pain
- Need for IV fluids
- Do SNFs typically have weekend MD coverage?
- And night MD coverage?
- No
- No
Medicare typically pays for the first ?? days of a patient’s stay at a SNF.
20
What percentage of patients at a SNF return to the hospital or die before returning?
20%
What is the maximum amount of PT that can typically be gotten for a patient in custodial LTC?
3 days/week
What is the average monthly cost to stay in custodial care at a nursing facility?
$8,000
True/False.
Medicaid does not cover LTC.
False.
Medicare does not cover LTC.
Medicaid does.
