Cathy Cress

Expert in Aging Life and Geriatric Care Management

How Does a Geriatric Manager Rate Her Husband’s Discharge?

Discharge Before The Affordable Care Act

Families leaving the hospital used to scramble to get mom or dad home from the hospital safely – often quickly. and chaotically. In some parts of the country, families were given notice that the following day – or perhaps in two or three days – the older adult would be ready to leave the hospital.

Word of the discharge sets the family in motion – seeking resources, exploring options, and lining up care- that shockingly may be themselves. For many families, this is the beginning of confusion and horror from the cost of care, the difficulty finding advice, the myriad health, functional, and safety needs to address, and finally the challenges of finding peace of mind after the discharge.

As a result, many older American were readmitted to the hospital between 30 and 90 days- doubling the discharge, the family confusion and often ending the older person in a nursing home

When the Affordable Care Act was passed, Medicare lashed at that huge problem. They began fining hospitals and all that began to slowly change. Hospitals paid more attention to hospital discharge.

 You can see that at Stanford University Hospital where my husband just had open-heart surgery for a defective valve.

His discharge is today after being here 7 days including today. He has had incredible care as I have documented in my last blog. We knew about discharge from day one. It may have helped that I am a geriatric care manager and knew this would be a critical transition so I asked about it. At Stanford, they have a unique discharge process and I was prepared for it.

Instead of one discharge planner, we will have three. The first is what I have been advocating since I wrote the chapter on  Care Managers and Hospital Discharge in Care Managers Working With the Aging Family. She is

our hospital care manager, Christine Harris BS BSN who has followed all our transition and been to see us every day, will be here to go over the discharge with Pete and me.

The second was a Cardiac RN coordinator who was with us yesterday and spent an hour going over-discharge and care in the first few months post-discharge with a binder that she reviewed at the meeting and we will have to take home.

Stanford Cardiac Discharge made physicians’appointments for the next month with the primary physician in a week and Pete’s cardiac surgeon in a month followed by a cardiologist who will be Pete’s follow from now one. Home Health through Medicare was set up by the appointment and we will have an RN, PT, and OT coming to our home post-discharge.

 All are at Stanford by Pete’s choice because we want to stay within one medical system although we live an hour away in Santa Cruz. We also have a primary physician 5 minutes away that he will see next week and use for any emergencies. Both systems communicate well already. A list of these appointments is in the binder

The third discharge planner is a Stanford pharmacist who will meet with us to go over the medication that will go home with my husband I already have a complete list that was prescribed.

Here are some steps that a care manager should follow in discharge that Stanford already implements

  • Help the family determine whether the family caregiver is willing and able to deliver care-
  • Pete has me my daughter Jill and her partner Tom McKay, who is a Ph.D. RN. We are all willing
  • OR suggest organizing other family members to deliver care-
  • Our family have a great team now
  • OR suggest hiring private duty care providers-
  • we do not need care Pete is walking, on limited meds stable after heart surgery
  • Advocate for the family to be included in the discharge meeting-
  • We were very included
  • Involve family in Home Care
  • We were very included
  • Request that the discharge planner share the hospital discharge list-
  •  We have an entire booklet plus will have met with 3 discharge planners
  • Assess the family caregiver’s willingness and ability to deliver care –
  •  We are willing
  • Reassess the client with comprehensive functional, psychosocial, depression, mental status- that was done by Cardiac Nursing Dept, Pt, OT, Respiratory and I will have reports
  • Measure the risk of readmission-
  • Pete has a slight risk. He never had any pain, moved out of ICU in a record 20 hours, and out of step down ICU but his heart rate in high so slight risk
  • Help the family determine whether the family caregiver is willing and able to deliver care
  • we are willing and able
  • OR suggest organizing other family members to deliver care-
  • no need but have friends delivering meals every two days
  • OR suggest hiring private duty care providers-
  • not needed

  • More after discharge

How Important are Nurse Care Managers?

 

My husband Pete and our family have our own RN case manager.

Pete had open heart surgery 3 days ago at Stanford Hospital. The utility and utter comfort of having a care manager hit me personally on this health care journey.

Our Stanford Cardiac Care Manager

Stanford’s cardiac unit is a wonder to behold. Your family touchpoint is, of course, the care manager. She is your navigator, comforter in chief, and patient-friendly-dispenser of information framed in a  digestible synopsis.

In her warm yet filled with authority voice, our care manager Christine Harris RN BSN greeted us in pre-op and explained what would happen during the surgery. She soothed our fractured nerves. Facing open heart surgery was, as with all patients, like taking a long trip you researched well but never understand the whole journey nor the wrong turns you just might take. 

It had taken Pete 7 years to get to this point as he was one of a category of 2% heart patients that had no symptoms. He had not wanted to do the surgery and they respected his wishes. In the last few months, they found his heart not getting enough oxygen, so he finally decided to do it. The day before surgery he was chopping down a plum tree, among the many, in our California yard.

12 Hours of Open Heart Surgery

As the open heart surgery was 12 hours long- most of it pre-op and then post-op, Christina our care manager became our navigator through the long hours of waiting  She came to us at every stage, shared information that calmed us and made us feel health literate about what was happening to Pete.

Trouble on the Tracks

But in the late afternoon, when we were feeling so sure he was sailing through the procedure, we became alarmed. Stanford has a color-coded electronic screen of all patents in surgery showing you their operating stage. We were watching this large electronic surgery board, much like an airline flight board with scheduled take-offs and landings. Pete was about to land in post-op then before our eyes -reversed to the operating room. Pedro, the navigator of the board,  had no idea what happened but told us Christine would be down to talk to us. My two daughters and I were then on red alert and our lovefest with the ease of all this dumped back into reality.

Tear in the Heart

As any case manager would, Christine arrived with calming information. As they were about to close up Pete’s chest after the new valve went in flawlessly, they noticed a small tear in the aorta. She explained that the aorta, like all of Pete’s body, was almost 8o- years old and thin enough to tear. Dr. Fichbine saw bleeding, along with the  30 residents who were watching, did a small patch, closed up the incision then sent him on his way to post-op. In reality, it was more serious, but she shared the steps taken and he was in truth patched up and on his way to recovery. She gave us the right information mellowing it out enough that we went from Post  9/11 color-coded red- terrorist attack imminent —to calming green – low threat. Pete arrived back in post-op and we got to see him at 7:30 that night 13 hours after his trip through the surgical theaters.

Christine is also our head discharge planner and goes to see Pete every day, along with Dr. Fishbine on rounds. She will be there at discharge when she, a Stanford pharmacist, and a cardiac nurse share discharge plans.

So thanks to all the care managers who like Christine, guide us over troubled waters, comfort us and hold our hands while they navigate us to a safer shore.

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