Discharged to Community
Polypharmacy of 7+ medications Must meet one additional criterion: Lives alone
Is without a source of emotional support
Is without a support system for care
Discharged with a service referral
High risk for falls
Inpatient hospitalization in past 12 months
Identified in-depth psychosocial need
High-risk medication prescribed

At baseline, patients needed to be age 65 or older, have seven or more prescribed medications, and be returning home under their own care or with home health services. Additional risk factors for inclusion in the RCT were identified in transitional care literature as reasons patients experience adverse events post-discharge. These include: living alone, frequent hospital admissions, an unstable or nonexistent support system, and high falls risk. Others were taken from a section in the medical record completed by the inpatient discharge planners for identification of in-depth psychosocial needs. They are defined as any non-medical factor that may present significant barriers for the patient or caregiver in having a successful post-discharge outcome (Table 14.2). The most common reasons for referral during the RCT were prior admissions, living alone, high risk for falls, and one or more in-depth psychosocial needs identified.

Table 14.2 In-Depth Psychosocial Needs

Pre-assessment

Once a referral is received, EDPP social workers perform a pre-assessment of the patient’s discharge plan of care. This pre-assessment allows the EDPP social worker to gather medical and psychosocial information relevant to the inpatient stay and to identify potential barriers to a successful transition. The EDPP worker will consider the following to formulate questions in the pre-assessment: admission reasons, treatments provided, changes in functional status, coping or mental health issues for the patient or caregiver, capacity for self-management, support system at home, financial or insurance barriers to care, presence of a primary care physician, and presence of complex care. The following questions are used to guide the pre-assessment:

• What was the reason for admission? Was it elective or an emergency?
  
• What is the follow-up plan of care? What is the plan for:
  
  
  
  • Home health services
    
  • Medical follow-up appointments
    
  • Blood work
    
  • Durable Medical Equipment
    
  • Pain management
    
  • Wound Care
    
  • Medications
  
  
• What was the outcome of the hospital stay? Is the patient awaiting any results? Were there any complications, new diagnoses, or new treatments during the hospital stay?
  
• What psychosocial factors are already known about the patient’s situation?
  
• Who is the patient’s emergency contact? Is one present?
  
• Which potential community and/or diagnosis-related resources could aid this patient?

With this information, the EDPP social worker creates a picture of what happened during the inpatient hospital stay and what may be happening at home as a result. The pre-assessment also identifies what is not known about the patient’s home environment that may impact health and well-being. At the end of the pre-assessment, the EDPP social worker generates a list of questions addressing potential problem areas and unclear issues to direct the next step of the process, which is assessment.

Assessment

The goals of the assessment phase of the intervention are to verify understanding and ability to comply with follow-up recommendations and to ensure patients are receiving appropriate health and community-based services. The EDPP social worker seeks answers to the following questions.

Follow-up medical care

• Do patients have a copy of the discharge instructions?
  
• Have patients filled their prescriptions? Do they have any questions about their medications?
  
• Have home health services started? Did the nurse reconcile the patients’ medications? Did other services start (physical therapy, occupational therapy, social work, speech therapy)? Do patients know their schedules and understand the services they are receiving?
  
• Are patients aware of their follow-up appointments? Do they anticipate any barriers in getting to them?
  
• Do patients have a primary care physician? Does that doctor know they were hospitalized? Do they know the process to transfer their medical records to an outside physician?
  
• Do patients know whom to contact should they need information about their medical care?
  
• Do they have any other concerns or issues relating to medical care?

Support

• Do patients have a family member or friend that can help?
  
• Do patients belong to a faith community or social group that can help?
  
• How confident are patients that they can rely on these people if assistance is needed?
  
• Do patients need additional community services? Which needs are not currently being met?
  
• How are patients coping? With whom can they talk to about their emotional issues?
  
• How is the caregiver? Do they need support or resources?
  
• What other psychosocial factors need counseling and/or resources?

With the advent of diagnostic related groups (DRGs) and other changes in insurance reimbursement, patients are leaving hospitals in shorter periods of time often with complex care needs. Many patients and caregivers are unable to anticipate issues while in the hospital or do not disclose information for a number of reasons: limited time to talk about issues of concern, they don’t think the issues are important, or sometimes emotional issues like shame and guilt prevent disclosure of important information. For this reason, many new issues come to light after the patient returns home to assume self-management of care without the support of hospital staff. Even the best discharge planning cannot account for all possible scenarios.

EDPP is able to identify post-discharge problems and provides intervention promptly to stabilize the situation. Patients self-report an increased willingness to be honest and share openly with EDPP social workers about their home situation and care needs, things they may not share with their medical providers. Once these issues are disclosed, EDPP social workers are able to address the psychosocial and environmental factors that impact health outcomes while creating linkages to sources for medical intervention.

Intervention

Issues identified during the initial assessment are addressed during the EDPP intervention phase. During this phase, patients and caregivers are encouraged to take an active role in care with the support of the EDPP social worker. EDPP social workers engage in the process of collaboration with health care and community-based providers to resolve immediate discharge issues and to establish a plan of care for management of ongoing needs. New issues are often identified while others are resolved. For this reason, the duration of the intervention varies from one day to a month or longer depending upon the patient’s situation, the responsiveness of the outpatient providers, and the availability of resources to meet patient needs.

At the conclusion of the intervention phase, each patient and caregiver are provided with contact information for the EDPP worker or the Anne Byron Waud Patient and Family Resource Center should future issues arise. Information about the post-discharge intervention is documented in the hospital system for review if patients require future care.

Findings

A randomized controlled trial with 746 participants examined the impact of the EDPP intervention: 360 participants received the full EDPP intervention upon discharge while 384 participants received the usual care a patient can expect upon discharge. The typical intervention was completed in 8 days with an average of 5 calls required to resolve the issues identified during the initial EDPP post-discharge assessment. The EDPP social workers identified issues in 83% of intervention group participants. For 74% of these individuals, the problems did not emerge until after hospital discharge. Common problem areas largely centered on patient self-management, coping, education, and service needs. Common interventions involved educating, providing emotional support, and facilitating communication.

Surveys completed during the first intervention phone call and again 30 days post-discharge revealed that patients receiving the EDPP intervention reported:

• Increased understanding of the purpose for taking their prescribed medications.
  
• Decreased stress managing their health care needs.
  
• Decreased caregiver stress managing patients’ health needs.

When compared to the usual care groups’ survey responses at 30 days post-discharge, participants receiving the EDPP intervention reported:

• Greater understanding of their responsibilities for managing their health.
  
• Greater communication with physicians within 30 days of hospitalization.
  
• Greater scheduling of follow-up medical appointments.
  
• Greater attendance at follow-up medical appointments.
  
• Decreased mortality rates.

Analysis of the EDPP model reveals that the social-work-based intervention may be having a positive impact on mortality rates within the first 30 days post-index discharge.

There should not be a paragraph indentation here. It is the second sentence of the paragraph. Intervention group participants in the RCT had a mortality rate of 2.2% compared to 5.3% in the usual care group.

Case study #1

Referral

The patient is an older adult, recently paralyzed from gunshot wounds, referred to EDPP for high-risk prescribed medications, and a questionable support system to sustain his care.

Pre-assessment

In the pre-assessment review of the medical chart, the EDPP social worker identified several areas that needed to be considered in the patient’s continuity of care. The patient did not have insurance, but he qualified for Rush’s Charity Care program. The patient did not have a community primary care physician (PCP). The patient was discharged with a referral to the Illinois Community Cares Program (CCP), a state administered program, funded by a Medicaid waiver, intended to support older adults and disabled persons to maintain independence in their homes and communities versus a more costly alternative of moving into a skilled nursing facility. CCP services assist with household tasks, including cleaning, shopping, laundry, and meals and some personal care tasks (www.IDOAhomecare.org). Based on literature and EDPP experience with older adult and disability issues, the EDPP social worker premised that the patient’s caregivers might need additional support and that the patient might experience depressive symptoms as a critical component of pain.

In summary, the EDPP social worker identified the following areas as important factors involved in the assessment of and intervention in the patient’s care coordination: Rush Charity Care insurance limitations in accessing Rush and non-Rush provider systems; the need for a PCP in coordination and management of patient care; CCP referral for community services; caregiver stress; pain management with high risk medications; and possible depression or mental health concerns.

Assessment

The EDPP social worker communicated with the patient’s primary caregiver, a 26-year-old relative with four children under her care. She related that the patient was having a difficult time in communicating with his providers. The patient’s caregiver expressed that their immediate concern was that the brace the patient received during the recent hospitalization at Rush was causing him acute pain. The conversation also identified the following issues: the patient could not afford the prescribed pain medication and Rush Charity Care insurance does not cover medications. The patient’s caregiver indicated that she had obtained a generic medication, but she was not sure if it had an equivalent potency compared to the name brand. In order for the patient to resume outpatient rehabilitation (OP Rehab) services in the community, the patient needed a doctor’s order, yet the patient’s caregiver did not know how to obtain an order. The patient did not have a PCP that he and his caregiver could collaborate with in getting health and medication issues resolved.

In discussing the difficulty the patient was having in communicating with his providers, the caregiver described that the patient exhibited agitation, lack of interest, change in sleep patterns, and reduced appetite – all of which are depressive symptoms. In addition, the patient and caregiver were confused about the plan for care, and this confusion was exacerbated by the patient not having insurance to access non-Rush provider systems.

The patient’s caregiver indicated that she did not understand how to follow through on the CCP referral for in-home support services. The caregiver reported feeling overwhelmed in providing care to the patient and her children and shared that she coped by “taking one day at a time.”

In summary, the major areas to consider in the intervention are: resolution of pain caused by the brace; addressing financial constraints to obtain medications; obtaining a doctor order required to resume OP Rehab services; addressing depressive symptoms, health literacy, and confusion around coordination of patient plan of care; obtaining CCP referrals and other community service options; and diffusing caregiver stress.

Intervention

The EDPP social worker collaborated with providers and the patient’s caregiver in approximately 15 calls placed over five days.

Resolution of pain caused by brace

The EDPP social worker identified the brace manufacturer (known from other cases) and contacted the provider’s office on the Rush campus (most convenient to patient). The office representative agreed to see the patient on a walk-in basis.

Financial constraints to obtaining medications

The EDPP social worker collaborated with a social worker who works with older adults at the local county health clinic on a plan for the patient to see a PCP at the clinic and thereby obtain prescriptions, at no charge, through the clinic.

Obtain doctor order required to resume OP Rehab services

The EDPP social worker confirmed with the OP Rehab provider that a doctor order was necessary for the patient to resume services. The EDPP social worker then requested that the Rush hospitalist complete a fax order and verified receipt of the order by the OP Rehab provider. The EDPP social worker assured a Rush hospitalist that a goal of the care plan was to connect the patient to a PCP who could monitor the patient’s care.

Depressive symptoms, health literacy and confusion around plan of care

The EDPP social worker collaborated with OP Rehab therapists in regard to patient difficulty with communication, depressive symptoms, and the caregiver’s confusion around coordinating the patient care plan. The therapists offered that the patient’s rehab team included a psychological counseling resource and encouraged ongoing collaboration among the care providers to reinforce a cohesive structure for health literacy, patient advocacy and patient self-determination. The therapist suggested that collaboration among the care providers to reinforce health literacy and patient responsibilities would benefit patient care. The EDPP social worker facilitated communication between the patient, caregiver and providers.

CCP referral and other community service options

The EDPP social worker followed up with the CCP program to determine the status of the referral and facilitated new referral when original was not located in CCP system. The social worker provided the caregiver with information to access community older adult and disability resources.

Caregiver stress

The EDPP social worker and patient caregiver discussed caregiver stressors and acknowledged the universality of the impact on caregivers as described in caregiver literature. The caregiver expressed an interest in attending a caregiver support group to share and learn skills and strategies for effective caregiving. The EDPP social worker educated the caregiver about a program, Powerful Tools for Caregivers, that is provided at the Rush Older Adult resource center.

Case study #2

Referral

The patient is a 78-year-old woman admitted to the hospital for complications after a hip replacement. She was referred to EDPP due to a prior hospitalization in the past 12 months and a high risk for falls.

Pre-assessment

In the pre-assessment review of the medical chart, the EDPP social worker identified a medical follow-up appointment scheduled. The patient was discharged with wound care and pain management needs, as well as limited mobility. Home physical therapy and nursing services were ordered before discharge. Potential areas for focused intervention included: ability to attend scheduled follow-up appointments; wound care and pain management; changes in mobility; and home health services.

Assessment

During the assessment with the patient, the EDPP social worker learned that the patient was experiencing declines in cognitive and physical functioning and was in severe pain, as she had run out of pain medications. Her daughter, who usually assists with medications, was out of town for the weekend, and the patient had forgotten to refill them.

The patient shared her medical history and experiences with non-traditional medicine. She noted how her life changed after her accupressurist of 30 years died. She felt her accupressurist has kept her pain to a minimum. After her accupressurist died, she sought assistance from traditional medicine which included a hip replacement. The patient states she lost her ability to walk since this procedure and the subsequent seven surgeries. Two years ago, the patient fell, fracturing her neck. She has experienced short term memory loss since the fall.

The patient felt her support system was generally available, and she expressed appreciation for assistance provided by her daughter and spouse. However, she felt they did not understand or believe the severity of her pain and its impact on her functioning. Her husband was still working and according to the home health staff, minimally involved in her care. Additionally, the patient expressed frustration at her daughter’s and spouse’s lack of understanding or empathy for the cognitive changes she was experiencing. According to the patient, her family members’ expectations of what she should be able to do were unrealistic given her new limitations. The patient reported being home alone most of the day, which was a challenge due to her mobility issues, high risk for falls, and memory loss.

The EDPP social worker assessed the presence of depressive symptoms due to the patient’s functional decline, loss of independence, chronic health problems, pain, and family conflicts. She expressed frustration with “being old and sick” and felt like a burden to her family. The patient expressed feeling overwhelmed by her current care needs and had difficulty organizing her care plan. This was compounded by her family’s frustration around her healing process, as they perceived her as “not trying hard enough.”

In later conversations, additional barriers relating to incontinence was identified. Due to her changes in mobility, the patient was unable to go to the bathroom successfully in public restrooms that did not have grab bars. Her shame led to loss of dignity and feelings of greater social isolation. Issues for intervention included: coping with pain and obtaining medications; depression and coping; conflict with support system; caregiver stress; functional and cognitive decline; and incontinence.

Intervention

Coping with pain and obtaining medications

The EDPP social worker communicated with the home health nurse and physical therapist about the patient’s pain and safety issues. They communicated their awareness of the severity of her pain and cognitive issues that may have contributed to the medications going unfilled. With the help of the home health nurse, the social worker ensured that the family was able to monitor administration of medications and refills as needed. She also spoke with the home health nurse and surgeon for a better understanding of pain expectations for use in conversations with this patient.

Depression and coping

The EDPP social worker allowed the patient to share her feelings around her many physical and cognitive losses and changes and validated the patient’s experience. The EDPP social worker contacted the home health agency about adding a master’s-level social worker to the home health service plan and spoke with that social worker about this patient’s depression, including a potential need for medications. The EDPP social worker referred the patient to a community-based mental health counseling service, a friendly visiting program, and alternative medicine resources within the community.

Conflict with support system

The EDPP social worker allowed the patient to share her feelings regarding her support system and sought input from the home health nurse around the family’s dynamics. The EDPP social worker then facilitated a phone conference with both the patient and caregiver, mediating the communication. Based upon the conference, the EDPP social worker recommended increasing the hours of a private duty caregiver to provide care in the hours the caregiver could not to relieve both patient and caregiver stress (patient was financially ineligible for in-home services through The Department of Aging). The EDPP social worker encouraged the caregiver’s and patient’s willingness to accept help and provided support around the loss of independence.

Caregiver stress

The EDPP social worker spoke to the daughter individually, allowing her to share her emotions and receive support around the challenges she faced in her role as a caregiver. The EDPP social worker provided education to the daughter about memory loss and discussed the meaning of the patient’s changed role and functioning.

Functional and cognitive decline

The EDPP social worker assessed the patient’s ability to address her own care due to her cognitive changes. She educated the family about realistic expectations and the need for increased supervision during the day. The EDPP social worker provided resources for additional therapy such as neuropsychological testing and, as such, coordinated with the home health social worker around the need to increase private duty caregiver assistance. She provided emotional support to the patient around the loss of dignity, increased shame, and increased dependence.

Incontinence

The EDPP social worker talked to the home health nurse (who would follow-up) about incontinence issues, including resources shared with the patient to assist with toileting in public restrooms. Her daughter was made aware of these resources as well.

Lessons learned

Effective transitional care requires collaboration of many entities from different disciplines, settings, and educational backgrounds. As with any model, it is necessary to keep stakeholders involved and invested in the success of the program. This can be done by keeping lines of communication open and promoting honesty and accountability among care providers. Patients respond positively to the collaboration of providers and are better able to take responsibility for their self-care when there is a structure around them to support this endeavor.

Successful study of clinical and coordination interventions requires focused attention on the substance of the intervention as well as a willingness to thoughtfully characterize and categorize the intervention to allow for appropriate study of the program.

Summary

The Enhanced Discharge Planning Program (EDPP) is a program providing telephonic short-term social work care coordination for patients discharged from Rush University Medical Center after an inpatient hospital stay. It is tailored to provide assistance to older adults at risk for an adverse event once home from the hospital. The program’s goal is to prevent avoidable adverse events post-discharge by: (1) ensuring patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs; (2) connecting patients to outpatient health services with particular emphasis on the first physician follow-up appointment; and supporting caregivers to reduce stress and burden. Outcomes from a RCT of the model suggest that many transitional care issues do not arise until patients return home and begin to engage in self-management roles. For this reason, it is important to provide a bridge between the hospital and home that addresses the medical and non-medical factors contributing to health and well-being post-discharge. EDPP links “silos” of care, bridging the great divide between social and medical models.

References and suggested reading

Altfeld, S., Golden, R., McFolling, S., et al. (2009) An innovative model for transitional care: enhanced discharge planning program. Collaborative Case Management, 7(2), 7–9.

American Hospital Association. (2009) Hospitals in the Pursuit of Excellence Case Study: Social Workers Enhance Post-Discharge Care for Seniors. American Hospital Association, Chicago, IL. Available at: http://www.hpoe.org/case-studies/4340001768.

Brown, R. (2009) The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illness. Mathematica Policy Research, Princeton, N.J. Available at: http://www.socialworkleadership.org/snw/Brown_Executive_Summary.pdf.

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