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Welcome to Healthcare Redefined: Advocating for Aging Adults and Their Families, where we empower families to navigate the complexities of aging and healthcare. Presented by Your Nurse Advocate Consulting, we share real stories, expert advice, and practical tools to help you and your loved ones confidently navigate aging with dignity.
We explore topics like creating collaborative care plans, demystifying Medicare, handling healthcare crises, and preparing for the future. Join us as we transform uncertainty into understanding.
Pam Dunwald: [00:00:00] Before we get into this week’s episode 12, we wanted to share some exciting news with you. Well, if you’re new to caregiving or you’ve recently found yourself coordinating care for a parent or a spouse or a loved one, you probably know how fast it can go from, “We’re fine”, to “I am so overwhelmed and I don’t even know what to do first or where to start”. That’s exactly why we created our new family Caregiver bootcamp. It’s a practical, step by step workshop to help you get organized and feel more confident. It’s a two hour live workshop on March 26th and registration opens on March 11th at $37. It is really affordable and our way of giving you a cost effective way to help and support you on this caregiving journey. In the bootcamp, we’ll walk you through the key things every new caregiver needs early on, what information to gather, what to track, what questions to ask, how to create a plan that actually works in real life, and a little bit about how to talk about those tough subjects. And you won’t just leave with good ideas, you’ll literally walk away with a simple 30 day action plan so you know exactly what to do next to get your caregiving journey off to an organized and less stressful start. If you’re listening, thinking, that’s me or this is my sister or oh gosh, this is my friend, we’d love to have you join us. If you can’t make it live, don’t worry. After the boot camp, it will be available ongoing on our website under the course slash education tab. To learn more and to register starting March 11th, just head on over to YourNursingAdvocateConsulting.com, and we will also have a direct link for you in this week’s show notes. Okay, now let's jump right into episode 12.
Pam Dunwald: [01:49] Welcome back to Healthcare Redefined, advocating for aging adults and their families. Hi, this is Pam, and this is our episode number 12: “Can We Go Home Yet?”: What Needs to be in Place Before We Discharge. So, hi, I'm Pam from your nurse advocate.
Linda Kritikos: [02:02] Hi, and I'm Linda. If you're caring for an aging parent and you've ever felt rushed, confused, overwhelmed, especially during a hospital stay, especially when they come in and say, “Oh, it's time to go”, or, “You're going home tomorrow”, and you're not sure what to expect or what to do, today's episode is for you.
Pam Dunwald: [02:22] We're talking about discharge planning, what it really means, what family should ask, and how to avoid the gaps that can maybe lead to unsafe transitions or even a return trip to the hospital. But before we jump in, I just want to share a quick note for our listeners. You may notice that we're going to take a short hiatus from releasing new podcast episodes after this one. The caregiving issues we talk about here are real and ongoing, and they're not going away anywhere soon, and we want you to know we will be back with more episodes. But in the meantime, we don't want you to feel like you're on your own.
Linda Kritikos: [02:59] You can still find a lot of practical help and step-by-step guidance from us on our website at YourNurseAdvocateConsulting.com, on all of our social media platforms, and especially on our YouTube channel, where we share a lot of tips and strategies to help you manage the care of your aging loved one.
Pam Dunwald: [03:18] Today, we're interviewing a hospital social worker and a discharge planner, Marsha Hall. We're going to talk about what family caregivers should ask for during a hospital stay before discharge. Marsha and I work together in home health and hospice, and I really enjoyed working with Marsha. She's very good at what she does, so we're really excited to have her on as a guest for this episode. We also want you to be aware during this episode what kind of things that a social worker can assist you with, especially during a hospital stay.
Linda Kritikos: [03:51] We're going to cover things like when discharge planning actually starts. When I was in nursing school, in nursing 101, the first thing they taught us is that discharge planning starts with admission. Unfortunately, in today's revolving door of going in sicker and coming out quicker, the difference between going home with support versus rehab or skilled nursing is a lot more complex. So we're going to be looking at what services and equipment can be arranged, and help you answer the questions in regards to developing a safe plan for going home.
Pam Dunwald: [04:29] Marsha, thank you so much for being here. Let's go ahead and jump in. In segment one what a hospital social worker discharge planner actually does. So Marsha, can you talk a little bit about what your role is before people go home? Um.
Marsha Hall: [04:46] With my work for people going home, we work closely with the team, is what I call it. We work with the therapists, the nursing physicians, and try to determine how things are going to be looking for that person before they're discharged. We do start this on day one. We take a little inventory. And one thing that differs for social workers is that we try to look at the whole picture of the person. We don't look just at their physical needs, their medications, that type of thing. But we look at what's influencing their decisions at home, what support they have, and those types of things also.
Pam Dunwald: [05:18] You shared a little bit, Marsha, what do you think is the big difference between the social worker and say the bedside nurse or the case manager or the physician or the hospitalist? What makes you different or what's your skills that you bring to the table?
Marsha Hall: [05:35] We're usually the ones that are a little bit more aware of what resources are out in the community to possibly help the person after they're being discharged back home or if they need skilled nursing. We tend to make those referrals. We make referrals to home health, supportive care services, transportation and the ADRC is another big resource that we use a lot for many different things.
Pam Dunwald: [06:01] The Adrc is the Aging and Disability Resource Center, and every county has one in the United States. So wherever you're listening from, it may have a different name, but basically that's your county agent that provides services for aging adults. So, Marsha, typically when does a social worker get involved with someone in the hospital? Do they get involved with everyone? How do you decide who you work with?
Marsha Hall: [06:30] No, we don't necessarily get involved with anyone. Everyone we look at, if they're going to have needs for going home is when we get more involved. And we also want to usually wait a little bit longer until they're more medically stable because it's not really fair to be planning for someone's needs that might be able to be fixed while they're at the hospital.
Pam Dunwald: [06:57] Okay. So what is one of the things that you wish families understood? If you could wave a magic wand over each family that came into the hospital that you were assisting with a discharge, what's one thing that you wish families could understand about the discharge planning process?
Marsha Hall: [07:11] Families and patients need to be honest with us about how things are going at home. Not to try to sugarcoat it or make things a little bit less, because the person always wants to get home so they maybe won't tell us everything that's been happening that could be fixed and or at least supported a little bit more.
Pam Dunwald: [07:32] That's a really good point, because there's nothing that would help to set a discharge up to fail if they're not honest, and how many times we've experienced families saying, “Oh, we want to take them home”, and then they're home for a couple of days. And they said, “This is way more than what we can handle”. And then we're trying to find services. So I think that's a great point that you made. So Linda, I'm going to let you go on.
Linda Kritikos: [07:57] To the next topic. So in looking at this and carrying this through to the next arena, let's look at the discharge timeline. What happens? I don't think people understand how much work it is or what exactly happens behind the scenes. We discussed that discharge planning starts with day one. But what other information do you need? And what about insurance coverage and other kinds of common bottlenecks in regards to getting someone home in an appropriate time? Can you talk a little bit about that?
Marsha Hall: [08:30] There are obstacles, of course, with the managed care programs. Each one of those is a little bit different. We've had some changes in our county just recently. We're finding that a lot of the skilled nursing facilities don't have contracts or they're out of network with one of the chief ones that's available in our county. That's making challenges for discharge to SNF’s a little bit harder. When you are choosing your managed care program, you need to look at those things to see, make sure that your facility, the facilities that you would want are covered under that plan.
Pam Dunwald: [09:09] And Marsha, who is typically responsible for finding that out?
Marsha Hall: [09:13] The Aging and Disability Resource Center usually has a person that is geared toward helping people with insurance coverages. Also, if you have an insurance agent that you work with, they should be able to also check to see who's in your network. You can call the plans directly, too. And they would be able to tell you which facilities are in network with that plan.
Pam Dunwald: [09:35] So, when someone's in the hospital, is there someone in the hospital that before a referral is made that is checked? How does that work or does that fall back on the family as well?
Marsha Hall: [09:49] We tend to help. The nursing homes will know who they're in contact with, so we can always check with them. And also, the home health agencies are also aware of which ones they are in connection with. So those are the two. The biggest thing with the insurance companies, generally the hospitals have contracts with most of the managed care programs. There's just a couple that we don't have. But if a person comes in through the E.R. then and is admitted, then they do get covered.
Linda Kritikos: [10:22] So what type of information do you need from families to build a safe plan in regards to sending them home? What type of info do you need from them in regards to this discharge process?
Marsha Hall: [10:35] I tend to ask people how things have been going at home and what services maybe they already have in place, and then judge their awareness of what services are out there. Are they aware of Meals on Wheels? Are they aware of different transportation things? Are they aware of different supportive services, those types of things. And then what the house layout is, does a person need to go upstairs to the bathroom? Or is everything on the main floor that they can access more easily? Are there steps to get in and out of the house again? We work with a therapist on those things to gather information.
Linda Kritikos: [11:12] Speaking of that, do you find that there's a bottleneck with waiting on PT and OT evaluations for safe discharge or prior authorizations or facilities that will accept them? Because I do know that a lot of them have to come out and do their own assessments and evaluations, and there's no guarantee that they're going to be accepting this individual to their facility. So, do you find those are pretty common bottlenecks in your arena?
Marsha Hall: [11:43] Yes. Before physical therapy and occupational therapy jump in, usually the person needs to be medically stable. That can delay things a little bit too, which is understandable. And then the prior auth, they can take some time if they're going to a skilled nursing facility or that type of thing to get those back. It kind of depends again on the insurance company and then also again finding which your preference for the facility might not be covered under your insurance, so sometimes you have to look farther away in that type of thing which delays things.
Linda Kritikos: [12:21] And I would think that would also be very hard on the family, especially if the facility is in their network, but there's no beds. So they have to go further out and they need transportation and driving an hour away to see their loved one because the facility they want to go to that's in the network doesn't have any beds available for them. This could be pretty much a strong delay for them.
Pam Dunwald: [12:48] And so Marsha, I just had a quick question on that topic. I think a lot of times people misunderstand depending on the facility, every facility, every hospital is different. So how do you handle it if someone doesn't know where to go? Do you have a list of facilities? Do you have a list of home care companies? How does that work? If you're trying to find someone to send a patient home with?
Marsha Hall: [13:17] Yes, we do have a list of different facilities. We ask their preference, and then we also provide them with their three top choices. We provide them with what's called the Medicare Compare, and anyone can go on that website and get that. You just type in your zip code and it'll bring up the closest facilities to you, and then you can compare and see what their star rating is for nursing homes and for home health agencies. Also, you can't always.
Linda Kritikos: [13:45] Do you think that people know what those are, what they actually mean, those star ratings?
Marsha Hall: [13:50] Not a lot. Some people do. Some people are a little bit more geared toward it. But most people that I work with, they go on their general opinion that they've heard from other people.
Linda Kritikos: [14:00] Word of mouth, I think speaks louder than the star rating that they do. I want to speak about that. There's this common question or this common statement that we get. We hear a lot from our clients that use the terminology, “The hospitals kicking my mom out in a day”, or, you know, “My loved one, they're always kicking him out, this is not fair. This isn't right”. So what do you think the gaps are in regards to that? Those constant continual statements that they're making in regards to, “They're kicking my mom out, I wasn't aware of this. Now they're going to send them home tomorrow and I'm not prepared for this”. So what types of gaps do you think need to be addressed and what happens with all of that when those types of statements get made from your perspective?
Marsha Hall: [14:55] Well, generally we don't kick anyone out. We start the discharge planning from the beginning, sometimes people don't always like our suggestions and what our answers are, so that sometimes is a hardship. We always have to have a safe discharge plan for anyone that's being discharged. That's a top priority. And insurance companies generally will respect that as long as it isn't drug out. And then the person always does have the right to appeal.
Linda Kritikos: [15:31] I mean, I think a lot of it is that they're so overwhelmed with all the information that they get from day one through the admission that I just sometimes don't think that they actually are listening. They may be hearing that mom or dad are going to be going out and they're not going to be here forever. We've got to find a place for them. These are some of the places that you can look at. I think sometimes there's so much information for them that they're so overwhelmed that they really just can't process everything. It becomes more of an “Oh my God, what am I going to do?”, instead of, “Okay, let's look at this rationally and logically and see where we take this.”. So I mean, from my perspective, I think from clients that I've worked with, I think that. In fact, I just recently had a client, where the hospital said, “Well, there's nothing more we could do for you here, so you're going to need to go home”. Well, the person is bed bound. The person is not able to turn positions, get up, or go to the bathroom. What do we do? There's no family around to be able to help with this. How does this work? How does this become a safe discharge with all of that?
Marsha Hall: [16:44] Yeah. It's also a very emotional time sometimes. Some families, with the mobile world that we live in now, live quite a distance away. So they haven't seen their loved one maybe for the last six months or so and haven't really noticed the changes because they talk to them on the phone, but they don't see the changes that have been happening. Now all of a sudden they're exposed to those types of things. So it is a very emotional type thing. It can also become a very expensive type of thing. Nursing homes and all the caregiving things can be expensive for the person. And so that's always a little bit of a challenge too.
Pam Dunwald: [17:22] And it is I mean, I think times have changed. I remember maybe five years into my nursing career, which is a long time ago, I worked on a unit where people could come in the night before their colonoscopy and get their prep. And things like that don't happen anymore. And people do come into the hospital a little more ill, and they do go home a little quicker than years ago because we used to have the luxury years ago where insurance would cover everything and they could stay longer. And I think some people still think that when your loved one goes into the hospital, they're going to be in there for a week or two. Oftentimes that's not the case. I think, Marsha, you made a really good point about families that may live out of town and maybe haven't seen their aging loved ones in a while. I think that might be part of it too. I think people don't understand, Linda and I just had this conversation the other day. It's unfortunate, but the insurance companies, whether it's a Medicare advantage plan or another type of insurance. I mean, they really are controlling health care now. They're really calling the shots. And so if they tie our hands, we want to do what's best for our clients. And Marsha, it sounds like you guys do a great job of trying to stay on top of getting everyone prepared. But they can appeal and we can help them appeal. But if the insurance company says no and they're at risk of having to pay privately if they continue to stay in the hospital, that's usually not a financial burden that anyone is ready for.
Linda Kritikos: [19:08] Right. And I think people being thrown into roles that they were not expecting or not prepared for, such as being a caregiver, now all of a sudden you're telling me someone has to stay home and take care of mom or dad because they need 24 hour care, and their spouse may not be physically able to do that. So now where does that caregiving role fall? Who does it fall to? So I think you're absolutely right, Marsha, that there are a lot of emotions and it's very dynamically changing. And it could be a very volatile situation. It can draw some families very close, but it can also tear some families apart.
Marsha Hall: [19:47] Sometimes families don't agree either.
Linda Kritikos: [19:49] Yes.
Marsha Hall: [19:50] Or the spouse feels they can do more than they really can. So one of the things we do try to do, too, is we try to have the caregiver come in and work with the therapist while they're working with the patient just to see. So they have a good view of what things are going to be at least a short term type thing.
Pam Dunwald: [20:06] That's a great idea. So there's a nugget. There's a tip right there for our listeners is if you have concerns or if they've had a change of condition, ask if you can come in and work with a therapist during a session and just see how you get some training and see if you are actually able and capable of being able to manage them in the condition that they're in. So that's a great idea, Marsha. Before we move on to the next segment, I just wanted to clarify one thing. We were talking about giving a list for home health and home health agencies, as well as skilled nursing home facilities and having them pick. I just want to make it clear. Marsha, if you could just reiterate this or explain that they do have a choice, could you talk a little bit about that?
Marsha Hall: [20:53] Oh, yes. Everyone always has a choice and they have the right to make their own decisions. As long as you know they're able to, even if we don't agree with the decision. So I think if they really want to go home, even if we're not recommending it, that is their right, and if they have a certain facility we try to honor that as much as possible, too, with the limitations that are put in front of us sometimes.
Pam Dunwald: [21:22] Sometimes, hospitals don't have their own home care or their own hospice or their own home health care agency, but some do. So I think it's really important that we just reiterate that it doesn't matter where you are and if they have their own or not, you have the choice. So if you know someone that works in another home care agency and that's in your insurance network, and it's maybe not the one that's affiliated with the hospital. I just want everyone to know that you do have a choice. And they may say you may hear sometimes from someone, we like to work with ours. It's easier. We can transition, but the bottom line is that you have a choice. It's your choice to choose whichever agency that you would like to go with. And so, Marsha, do you ever come up against that right at all? Probably not too much, but.
Marsha Hall: [22:21] Not too much because we don't have our own. But yeah, it's the home health agencies. It's more of who covers their area. And that can change to what their census loads are. And they might not always have all the disciplines that they need. So then you have to be a little bit creative with that.
Pam Dunwald: [22:41] You're absolutely correct. So speaking of that, let's move on to the next segment. Home rehab or skilled nursing. How do those decisions get made. So Marsha can you talk a little bit, you mentioned that you work with a team concept. So what determines whether someone qualifies for, say, home health or inpatient rehab or a skilled nursing facility or outpatient therapy? How are those decisions made and those recommendations made?
Marsha Hall: [23:07] Well, again, we depend on our therapists. I keep going back to that. But they do play a big factor in helping determine if they would be eligible for those programs. And the top thing we look at is what the patient wants, some people aren't open to having people coming into their homes. Some people are. Some people have a negative feeling about skilled nursing facilities. And so we've been really trying to change that they're not the old time nursing homes where you go and you stay forever. Most of them are more focused on the rehab now, and that's what people would go for. And sometimes just going for that 1 or 2 weeks after being in the hospital can make a big difference in the person's long term goals and life. So we try to look at those types of things for sure. We look at what their fall risk is, are they on a blood thinner that would create more injuries or that type of thing, and work with the doctors and the therapists on those issues also. And then if there's cognitive concerns, we try to be creative in that everybody usually does better in their home environment. So it's hard to judge a person that's in the hospital because they are out of their environment and they're away from their familiar items and that type of thing. So we try to be creative in doing the therapies and such to work with things, how they have it set up. Maybe at home. That's where, again, where it's good to talk with the person and the family to see how things are at home.
Pam Dunwald: [24:36] Yeah. And we don't have to spend a lot of time on this, but I think people sometimes misunderstand non-medical home care versus home health. Could you just talk a little bit about the skilled home health and the homebound requirement?
Marsha Hall: [24:52] Oh, okay. Yes. Skilled home health is usually covered by insurance, so that's one of the big factors. Then it includes a nurse and therapists and once in a while a social worker, but mainly the nurse and the physical therapist and occupational therapists. And they come into the home. It's not a definite amount of days that they would come in. It's kind of on an as needed or what they feel is needed where they look at things and work with the patient in their own home environment. So I feel it's a really big benefit for the patient. They can also look at the home. And sometimes it's just moving a chair six inches that can make a big difference for getting a walker through the room and making it a little bit safer. So it's just better. It's nice for them to be able to see the home and how things are working in the home. That way we're supportive. Home services is more where you have a bath aide that comes in to help once a week with bathing needs, or they come in and do some supportive care like cleaning the home, doing laundry, more of those types of things. And that's usually either private pay or if a person has managed Medicare program like Inclusa or Medicaid. They would pay for those types of things
Linda Kritikos: [26:11] Also, I think long term care. There's some writers within the long term care policies that could help cover some of those services on a temporary basis.
Pam Dunwald: [26:20] With the home health, the skilled and the non; a lot of people don't understand that homebound concept and usually I wouldn't think that with a hospital just discharge that if they're not permanently homebound they're usually homebound for a couple of weeks as they're recovering from surgery. But I wanted to just mention that sometimes I know when we would call and make referrals and we'd talk through the homebound status, sometimes the home health care agency would push back a little bit and say, well, I'm not quite sure they're homebound, but that is. Marsha, could you just say what that homebound requirement is for our listeners?
Marsha Hall: [27:04] Generally it is where it's an effort for a person to leave the home so they wouldn't be able to easily come in for outpatient therapy or those types of services in the outpatient world. They're generally allowed to go out for a haircut. They can usually go out to church. But it's more and they have become, I think, a little bit more lenient, at least in our area with those requirements. But they can't be going out to eat on the weekends or they can't be going to visit family, shopping, and those types of things.
Pam Dunwald: [27:33] Shopping. Yeah.
Marsha Hall: [27:35] Right. It's gotta be and it's an effort for that person to be able to do those things. That’s one of the bigger factors.
Linda Kritikos: [27:43] It can't be a consistent outing.
Pam Dunwald: [27:45] Okay. Thank you for that. So moving on. So what would be some of the red flags in your mind, Marsha, that would be raised when you're considering that maybe the discharge is not safe?
Marsha Hall: [27:56] If there's a fall risk, that's always again, one of the big things. And then again, cognitive concerns, or if there's not a consistent person that's going to be with that person. We hear a lot of times like, “Yes, I'm going to be working from home. I'll be there”. But then a few days later, the person's back because they kicked him out or they said, “Oh, I don't need anybody here anymore”. And things all fell apart. That's where it's important to be honest. And the person and the family do have the right to make the choices. Like I said, we don't necessarily agree with them. They still do have those rights to make those choices, even if they're not maybe what we feel are the best choices. But just to be honest and with the circumstances that's going on, it's important. And if we see discrepancies in that, that's sometimes the way I guess would be a red flag and we try to address it.
Pam Dunwald: [28:54] So we hear a lot at this word thrown around a lot. And just for our listeners, what does it mean when you say baseline?
Marsha Hall: [29:02] That always comes up almost every time. What's their baseline? It kind of means, I guess, to me what it means is where they were normally before they became sick; what level they were at. Were they able to do their laundry? Were they able to walk from the length of the house, or were they doing the dishes, making their meals? Those types of things are or were they getting assistance, you know, with those types of things, what were they doing normally before they became ill that now we're maybe seeing that they can't do would be gotcha.
Pam Dunwald: [29:35] And that's again, maybe a good reason for them to spend a couple of weeks in rehab to get them back to where they were before, to be able to do things independently. So, Marsha, how can families participate in the discharge or the decision process without feeling powerless? We know if their aging loved one is competent, they're able to make their own health care decisions. What recommendations would you have for families to try and stay involved, but to try and help them support their aging loved one versus getting in the weeds with some of the things that we could see, like when the parents feel like they're making decisions for them. Any recommendations you can give to families?
Marsha Hall: [30:21] Showing respect for the person that you're working with. Some patients are a little bit more obstinate about having their children or their younger person stepping in. So they just redirect it back. Involving the patient with the decisions being made and not overriding the patient or being more dominant. I guess that's when we usually see a lot of issues, is when the patient feels like they're not being listened to or this a lot of times, it's the spouse of the patient that feels like they're not being listened to. And their life is changing, too, possibly. So be respectful of that.
Pam Dunwald: [31:06] Mhm. Yeah. And I know and sometimes we hear that “This is not what I signed up for”. It gets difficult. So in your role as a social worker do you find yourself doing a lot of family mediation in some of these situations?
Marsha Hall: [31:22] Certain times, yes. I think a mediation course should be mandatory for social workers. And again, a lot of times it's just that people are seeing things differently. And so it's getting everybody on the same page, and it always comes down to what's important for the patient. It's what's best for them and how to keep them safe.
Linda Kritikos: [31:48] I think this is really the heart of social services. And this episode in regards to resources, social workers, from my historical background, working with them are really great in accessing and finding resources; sometimes the hard to find resources, but they really know how to coordinate and help with getting these resources. So can you go over a little bit of the types of resources that you can help with? A couple examples would be like home health or DME transportation. Just give us a little bit of a snippet of some of the resources because I know it can be boundless and endless and quite heavy. But can you give us a little snippet of the type of resources you can help with?
Marsha Hall: [32:39] Yeah, one of the major things that we sometimes will refer people to is, again, the Aging and Disability Resource Center, just because they are the organization that has the whole range of services under their wing, or at least they have the knowledge to do that, and they can also help with financial needs, if that's an obstacle of getting these services. So, we refer people to the Aging and Disability Resource Center for option counseling. A lot of times where they can look at the options that might be available to them, because there's so many different programs and us as social workers in the hospital don't keep up on those different programs necessarily, and what the funding is for those and that type of thing. So that's a big benefit for them now.
Pam Dunwald: [33:25] Marsha, does the ADRC help them with either Medicare or Medicaid application? Can they get help through the ADRC?
Marsha Hall: [33:35] Yes. Medicare usually has a disability or a first income person that would help with that, that can help with applying for medical assistance. And then they can look at the different programs under that to see, are they with family, would care be a good fit or there's other other little nooks and crannies. There's a dementia care program under the wing of the Medicaid tool that can provide some extra funding for caregiver support or Caregiver relief so the caregiver can go shopping once a week, those types of things. Like I said, I'm not an expert for sure on those different programs, but the Aging and Disability Resource Center does have those things available and can talk through that much, much better than I could. So that's one of the things. We also like home health services. We make referrals for those in our general area, there's just two different agencies that we can use because that's who covers our area. But we're very fortunate to have them, and they've been very good about responding to our needs. Durable medical equipment. A lot of times, people don't know where to get that or how to get that. We do have a loan closet, and I think a lot of facilities do. A lot of the hospitals do have what they call a loan closet where they can get a walker. Our therapists work with that also. They'll get the walker set up so it fits them. Or if they need a wheelchair temporarily, it's usually a six month loan program, but it can be extended if needed. Or if somebody needs a commode by bedside, sometimes we have those available, the Aging and Disability resource centers.
Marsha Hall: [35:22] A lot of times they will have like a loan closet also. And then, those are helpful things for somebody that needs something, especially short term. If they need something more long term, we can work with the physician to get the order placed to the durable medical equipment facility that can service them for a hospital bed or for a wheelchair or a different type of walker. Medicare generally will pay for those things if there's certain criteria that is in place. So that's a good thing. Transportation. That's another thing that we can try to help set up if they have frequent appointments. We can help provide different information for the different transportation services that are available in the area. Caregiver support. I talked a little bit about the dementia caregiver support. Those are some of the programs that we have in our area. But I think it would be good to check out to see whatever area you're in, if there is a caregiver support and just being able to share those needs and what you're going through with someone else that's experiencing the same thing I think is very beneficial. Then we also look at Meals on Wheels. If there's a meal site, sometimes the socialization is good for the person just to get out to be with somebody for a while or if they would want Meals on Wheels. We're very fortunate to have those in place in our, in the areas.
Pam Dunwald: [36:55] I think, and the safety resources. Could you address some of those? We get a lot of questions about lifeline or Life Alert or things like that.
Marsha Hall: [37:05] Mhm. Yeah. Lifeline is one of the things that I frequently recommend, and I usually say it's not for you necessarily, but it's for your care. It's for your family because then they know that you have a way to get help if needed. And it gives them a little bit more peace of mind if you can sell them on that idea.
Pam Dunwald: [37:25] That's a great, I have not heard that angle. Marsha, that's really good because they'll always say they don't need it.
Linda Kritikos: [37:32] Right. Mhm. Yeah. You find it hanging in the bathroom or on their walker or stuck in a drawer in the kitchen. Yeah.
Marsha Hall: [37:40] And that's the other thing I always tell them is that it doesn't work unless you're wearing it. So you need to have it on even when you go in the shower. Keep it on because that's what it's there for.
Linda Kritikos: [37:48] So what about things like, you talked about safety resources, but what about some behavioral health? We did touch on dementia. But what about other mental health issues or substance use support?
Marsha Hall: [38:03] Mhm. Well again,if they are disabled with mental illness and that type of thing, there's referrals that can be made to the family and children's centers if those are available in your area. I'm talking about places that I'm familiar with, but other areas might have different places. There's different counselors if they need that type of support we have. We are fortunate to have a hospice for bereavement and grief specialists or groups that meet in the area, those types of things. So there's different programs, usually in the community. I keep going back to the Aging Disability Resource Center, but they do put together, at least in our county and our neighboring counties, our resource guide book that you can usually find online that has the different programs that are available in the area and support type things for that. So that's another resource for people.
Linda Kritikos: [39:00] I think also the Veterans Administration also, and I know a lot of the ADRCs have a place where they can or phone number or contact person, or an office right there within the ADRC where people who are veterans can actually just go right there and access some of the resources that they might be entitled to as a veteran.
Marsha Hall: [39:23] Now, each county usually has a veterans service office. Yeah for sure.
Pam Dunwald: [39:28] Okay, let's move on to common discharge mistakes and how to avoid them. We just want to talk about when we're talking about, say, we're going to get home health or say we're going to get some other kind of service in the home. Who is the one responsible, and this is where I see sometimes things fall through the cracks, is, say you discharge someone on a Friday or on a Saturday. And there's the home care agency or the someone you're trying to arrange services with is not open, or they're you're trying to make a follow up appointment with the clinic and they're closed till Monday. How can families avoid that or who makes those appointments and how should that work?
Marsha Hall: [40:17] Generally when I make a referral, I ask the agency to contact me back about what, what their start date is and not necessarily the time, but at least what date they're going to be seeing someone. I think that's important. Then I always tell the families or the patient that they're going to be getting a call because sometimes you don't recognize the number, so you don't answer the phone, which is not a bad thing either. But it happens quite often that they don't respond. At our facility, if there's a need on the weekends, they usually flag us for Monday to follow up on that and make sure that that's in place. We do sometimes find patients that will just about tell you anything just to get out of the hospital so they agree to home health. And then when the home health calls to set up the time, they say, “No, I don't need that”. So those types of things happen, too. So families need to be aware of that. It might have been set up and it might have been in place, but it might have been declined when they were contacted, which is their right. So, I mean, I'm not saying that it is.
Pam Dunwald: [41:21] But it's one of those things where you could get a nasty call or a concerned call, I should say, from a family member. But they haven't checked with their loved one first and their loved ones may have canceled or may have said, like you said, “I don't need it”. So, that can happen. Are there any common discharge mistakes that can occur that maybe the families or the patients can help to prevent?
Marsha Hall: [41:49] A lot of times, Medicaid, our pharmacist or I think most hospitals, they have a pharmacist that goes through the medications and looks for interactions and those types of things. We always have a discharge sheet that goes home with the patient. But a lot of times, we've found that patients save the one from the previous time, and then they get confused about which one is the current one. So it's important to get rid of any old documents and just try to keep the current one and get rid of the past documents, but we find that doesn't happen very often. Another thing that we always ask for is for patients not just to bring their medication list,but to actually bring their actual bottles of pills or their medications with them when they come in, if it's possible, because then they can look through those medications and make sure that there aren't medications that are by a different name that are confusing for the patients, and they'll know what they're actually supposed to be taking, and put in the discard bag the ones that they shouldn't be taken anymore or that have been changed, those types of things.
Pam Dunwald: [42:58] And, one more thing related to those medications. One experience I had was when we had to discharge a patient who had dementia. The wife didn't come up for the discharge instructions. I mean, this wasn't my patient, but this was something that happened where I was working. And then the wife didn't come up. She wanted the aide to bring the patient down to the door so she could pick him up. And then they were going to drive to the pharmacy and pick up their medication. Well, when they got to the pharmacy, she declined the medication because it's one of the new blood thinners. And her co-pay was so large. So fortunately in case management, we did a phone follow up and found out that she never picked up the Eliquis. So is there any suggestions as far as should the pharmacy get involved? How can we avoid something like that? Do you have any suggestions, Marsha?
Marsha Hall: [44:01] Well, if there is a medication that is too expensive, I feel it's too expensive to notify their doctor that they did or don't have it just in case there's an alternative medication that they can have that would be cheaper.
Pam Dunwald: [44:20] But is there something that can be done before they're discharged from the hospital when choosing, say, an Eliquis or Xarelto? I mean, how is that decision made? And is there anything that can be done prior to discharge?
Marsha Hall: [44:36] Generally, I think the pharmacist will discuss if there's going to be a considerable copayment. They're pretty familiar with what the cost of different medications are. Generally they will give that person a general cost if that's a concern or if they feel it could be a concern.
Pam Dunwald: [44:57] And I think that's just good for everybody to know if you're getting a new medication, that's a question to ask. That's, consumer be aware. Ask what my co-pay would be if this is going to be expensive or if it's not covered. So that's for our listeners, if you're going home on a new medication or your aging loved one is, ask those questions about what my co-pays might be. So, Linda, I'm going to go ahead and pass that on to you for the next set of questions.
Linda Kritikos: [45:24] Okay. So we're a very mobile society right now. So a lot of individuals or families have sons and daughters or loved ones that are not necessarily just out of state, but also maybe out of the country. So what do you do when the decision maker is out of state? I mean, how do you handle that?
Marsha Hall: [45:50] We reach out to them by phone and discuss things that the nurse will, social worker will, depending on what the needs are and what questions we have. And that's not really an uncommon type thing. Sometimes we'll set up a care.com, like a virtual care conference or such with that person too, depending on what the needs are, I guess for the patient and what involvement the caregiver wants to have.
Linda Kritikos: [46:27] So what documentation helps with all of that? What do you usually ask for when you're talking to someone who you're wondering if they are able to make these decisions on their own? Are they making good decisions? What type of documentation are you looking for or would you ask for?
Marsha Hall: [46:46] A lot of times we already have a health care power of attorney on file. So I always check that to see if we do have one or not. And then if there's not one, generally I'll ask the patient or the family if there is one and have them bring it in if they do. Then the doctors are the ones that determine whether the person is competent enough to make those decisions. And sometimes they'll rely on what's called a Moca test from the occupational therapist to determine the guidelines. But a lot of times, just general conversations. But typically, the physicians also don't activate those powers of attorneys when the person's first coming into the hospital, because if they're sick, that can make a big difference.
Linda Kritikos: [47:33] Mhm. That makes sense.
Marsha Hall: [47:34] And bring questions and such.
Linda Kritikos: [47:37] So how do you handle families, because families are very dynamic. And so how do you handle sibling conflict? Or who the POA is if it's unclear who the actual POA is, because you may or may not have that piece of paper, but they say they're the POA.
Marsha Hall: [47:54] We always think that. Or a lot of families or a lot of caregivers and families always think that once the power of attorney is done, that it's activated. So then we are.
Linda Kritikos: [48:03] Yes, that's very true. Misconception. Yes.
Marsha Hall: [48:07] So we always have to go back and say, your parent or your loved one is still able to make their own decisions. It hasn't been determined that they can't yet. And it's only how the power of attorney only takes effect when two doctors or a doctor or nurse practitioner or a doctor and psychiatrist, psychologists have deemed them incompetent. So that comes up quite often. We have to redirect that and say those types of things.
Linda Kritikos: [48:37] And then but they can defer like a patient can defer, say, I really just don't want to deal with this. I'm too sick. My daughter's my POA. But can you just defer all questions and let her just make the decisions and sign the consents?
Marsha Hall: [48:53] Yeah, we tend to do that at times. We always try to make sure the patient also is aware though, because they're still decisional. Then they need to know at least.
Pam Dunwald: [49:05] If they're directing, if they're directing, say well I you know, you've explained it to. That's the thing about healthcare is it's never black and white.
Linda Kritikos: [49:16] It's very gray and muddy. Yes, yes. So how do you get everybody on the same page? Especially with the large families, sometimes even small families, how do you get everybody on that same page so that everybody's rolling in the same way?
Marsha Hall: [49:32] Generally you have to try to redirect them that we're all here to, what's to work on, what's best for the patient or your loved one. That's what we're all here for, and listen to them, I guess, and listen to what their concerns are. And you know why they think so. And so is not making the right decision. And those types of things. And usually when you can get them to focus back on what's best for the patient then they usually do come around. And sometimes I've had examples, one sibling in one room and another sibling in another room because they don't talk. And then you have to go back and forth between the two of them, and hopefully then the person does have a power of attorney for health care, and they have made that decision of who they feel is the most responsible person to make the decisions for them.
Pam Dunwald: [50:25] So is that speaking of advanced directives in healthcare, is that something that in the hospital a social worker can assist a family or a client, a patient, if they don't have one?
Marsha Hall: [50:35] Yeah, we do a lot of that. We help them with that. And then it has to be witnessed by two people that aren't related or aren't directly with their medical care. So social workers and chaplains are the only ones in a hospital that can actually witness those. So that's always important because sometimes we also review all the health care power of attorneys that come into the hospital and clinics to make sure that they are correct. A lot of times the biggest mistakes we see is that the witnesses dated it on a different day than the patient did, or the person developing it, or else, the witnesses have the same last name. It's like, I don't think this is probably kosher. So then we have them get that fixed.
Linda Kritikos: [51:20] So okay. So I'm going to give this over to you to okay.
Pam Dunwald: [51:25] And I just have in this next segment, I just really have just a couple of quick questions as we're winding this episode down. But when caregivers feel pressured or family members there are certain things, Marsha, that we can maybe recommend or what would be the best way for them to get their concerns addressed? And one of the things I'd like you to talk about is the care conference and what that is, and when that can be requested, or how that works as a tool for the family.
Marsha Hall: [51:58] Well, care conference can be requested at any time. We tend to hold them weekly with our swing bed patients, but then other acute care patients, we tend to hold them a little bit closer to discharge time, try to bring everybody there, especially if there's differences. One instance I had was the spouse really felt that they were able to take his wife back home again and his wife had dementia and was needing a little bit more help. And so we had a care conference and we had the sibling or the children present and the husband present. And then we gave them time to talk amongst themselves also and the husband finally came to the decision that the placement was necessary. At this time, I always explained to him that in my experience, I've been around for a while, that oftentimes the caregiver is feeling overwhelmed and trying to do everything. They're the ones that are healthier, so it goes downhill faster than the one that's being cared for. I tend to point that out, especially during care conferences also just to try to get them to realize that and to open their eyes to why there is a concern. That's been another little effective thing that worked for me at least. But yes, care conferences can be asked for or we ask a lot of times we ask for them when we see that there are concerns and how to get everybody on the same page, and we involve the therapist, usually the doctor that's available and then nursing staff, and a social worker, of course.
Pam Dunwald: [53:51] And Linda, I'm going to turn it over to you for some rapid fire practical tips. So hopefully we can share some quick wins.
Linda Kritikos: [53:57] Okay. What is the best time to reach a social worker? I mean, the family has questions or concerns. What would be the best time to reach you? And what are some of the things that the patient's family or the patient should bring to the hospital when they come in to help ease their transition into discharge? And what else would they be bringing in and how should they track all this stuff?
Marsha Hall: [54:29] It's nice if they would have a folder where they keep their important papers, like a copy of their insurance card, their healthcare power of attorney, their most recent list of their medications. I still feel like it's important just to bring in the bottles if possible, but sometimes that's not always necessary. I mean, not always available and able to do that. But bringing those documents in is helpful. And also, if you are the caregiver for the person, if you have been keeping a notebook about what things have been changing and occurring, if you could bring in those tips, that type of thing, that's helpful also.
Linda Kritikos: [55:13] What's the best time to reach a social worker for case management?
Marsha Hall: [55:18] Well, generally we're there Mondays through Fridays. If the hospital has a need, they will reach out on the weekends. And we don't ever object to that, that's for sure. But, generally, weekdays or Monday through Fridays, we're available. Generally mornings are a little bit busier because we're getting people out to the nursing homes and out to different things. But the afternoons are a little bit more where we have time to spend with someone that's not quite ready for discharge or having some other issues or needs, that type of thing.
Linda Kritikos: [55:51] Okay. All right. Pam? Any other questions?
Pam Dunwald: [55:56] No, I think we covered that. Just a couple of things as we wrap up, just to make sure, Marsha, that we covered everything. Can you give us an example? Can you walk us through a discharge that went really well and what made it work?
Marsha Hall: [56:13] Probably going back to the one where the spouse was feeling that he really could take his wife home, and then he was able to come to the conclusion. The other big benefit for that is a lot of times you can't get someone into a memory care facility Immediately from the hospital. That doesn't happen real often, or to an assisted living. Those don't those don't happen very often. But this one did. The family was very willing to look outside the box. I guess they were very willing to be present and do the care conference. They went and checked with the facility, did paperwork and dealt with all the financial issues with them promptly. We had to keep the patient for maybe one extra day, but it made the transition just so much easier because I do believe that if she had gone home with the husband, that the husband would have said, no, she's staying here. And he was the agent for her. So that was one that went really well. So it's just being open, and it's not always possible. But this one was where the family was available and they were open and they were willing to do whatever needed to be done. Check the facility out, do those types of things. Talk to them.
Pam Dunwald: [57:42] Is there one thing that families can do to help make your job easier, to help you help them?
Marsha Hall: [57:49] I guess to be open. Like I said before, what's the concerns, what's been working? What's not working? You try not to sugarcoat things that aren't so great going on at home, but that's a big difference. And also to have an idea of what facilities you might want if you have several options, that type of thing we usually will ask for. We have three local ones in our area. So we usually ask for first, second and third for that. And then go from that aspect and try to meet their needs.
Pam Dunwald: [58:39] Is there one myth about discharge planning that you'd want to clear up? I know we talked about this a little before, but is there at least one myth you can think of?
Marsha Hall: [58:50] That we're not trying to put everybody in the nursing home and take the family farm or the family house.
Pam Dunwald: [58:55] Okay. That's fair.
Marsha Hall: [58:58] There are so many different options out there now that, it's kind of fun to try to be creative and try to work things through.
Pam Dunwald: [59:07] And I know we didn't really talk about it, and I don't want to get, as we're wrapping this up, I just want to mention that years ago, we used to rule out assisted living if they weren't ambulatory and now some assisted livings across the country do what they call enhanced care. They can do two person transfers. So that really opens things up for other people.
Linda Kritikos: [59:32] A lot of them are even doing Hoyer lifts and sit to stands and they're almost becoming mini skilled nursing facilities in some areas.
Marsha Hall: [59:43] Yeah. Sometimes we'll accept somebody with a wheelchair now for sure. And they can have home health coming into the assisted living also, which is another thing that might enable the person to go back to their assisted living facility and have home health.
Pam Dunwald: [01:00:02] Mhm. Is there one thing that you wish families could stop doing or start doing when it comes to discharge from the hospital?
Marsha Hall: [01:00:13] Mhm. There's not really anything that's really coming to mind on that one.
Pam Dunwald: [01:00:19] Well I know as a nurse, when we were going through the discharge and I know this wouldn't necessarily be the social worker, but I think one thing I want to throw in here is, have another person present with someone when they're going home, so that there is another family member or there's another set of ears to hear the discharge instructions because as we all know, at that point in time, the patient, they will say and do anything to get out of it. They want to go home. “Yes, yes, I understand”, and sometimes they don't. So I always think it's good practice to have someone, another family member or even if it's a neighbor or friend, someone that will be present and listen to those discharge instructions. Linda, did you have any other thing that you think that you can add to that?
Linda Kritikos: [01:01:08] No. I just want to thank Marsha for coming to join us and for the work that she does as a social worker, supporting patients and families, sometimes during the hardest emotionally challenging times of their lives.
Pam Dunwald: [01:01:23] Absolutely. And if you're listening and you're in the middle of a hospital stay right now,here are a few takeaways for you to hold on to. And that's discharge planning starts early. Don't wait until the day you're told that you're going home. And as Marsha explained it, it shouldn't happen like that. There is a process. So if you have some concerns, ask for that care conference. If you're not ready or you're not quite understanding, the hospital staff and the social worker will lead that and they'll do whatever they can to help you.
Linda Kritikos: [01:01:57] Always remember that you are the consumer of health care. So you have the right to ask questions and to get clear answers and get clarification and get answers in a way that you can understand.
Pam Dunwald: [01:02:13] And a hospital social worker discharge planner can really be a key partner in connecting you with resources and building a safer plan. So that is another really key takeaway that we want our listeners to get out of this.
Linda Kritikos: [01:02:26] Also, just as another reminder, we are going to be taking a short hiatus from new podcasting episodes, but we're still here to support you.
Pam Dunwald: [01:02:35] As we mentioned before, you can find us at YourNurseAdvocateConsulting.com on our social media, our YouTube channel for more tips and strategies. And if you need more help, consider a free 30 minute consultation with either myself or Linda to address your specific situation, and we will share the resources for you for that in the show notes.
Linda Kritikos: [01:02:57] So if this episode has helped you, please make sure that you share it with a friend or a sibling or a caregiver or a loved one.
Pam Dunwald: [01:03:05] If you haven't already, subscribe, please leave us a review. This really helps more families find us and find our podcast.
Linda Kritikos: [01:03:14] So until next time, take good care of yourself. And Marsha, again, thank you for joining us.