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