Who gets to go home? 3 short case studies

One of my biggest responsibilities from a hospital standpoint is providing discharge recommendations. Hospital stays are notoriously short and it is a priority of the case management staff and doctors to determine discharge location, for which they recruit OTs and PTs to assist. But determining discharge readiness and placement is more of an art than a science, no flow chart can be easily developed to guide a novice through the process. So here are 3 case examples of similar patients and situations, whom I saw on the same day, and my rationale for their discharge locations.

All three of the individuals were over 80 years old, with moderate dementia. They were all admitted with altered mental status caused by pneumonia and concurrent urinary tract infections. They were all living with family members prior to admission, who have each made a goal to keep the individual at home as long as possible. They are each oriented only to person at this time, but recognize their family members who were at bedside. Each person required max assist for bed-chair transfer and max assist for ADLs during OT eval.

Patient “Alan” lives with his also elderly brother. They have been living together almost their entire lives, and until about 5 years ago were very active in several community activities. I think it is fair to say that they are brothers and also best friends. Alan has been declining in recent years however. He is normally able to walk at home but is very unsteady, requires a lot of assist on the steps to the upper floor, and has had multiple falls at home endangering him and his brother. Alan's brother tearfully states that he is unable to help him after falling, which is becoming more frequent. Alan has not been able to leave the house for some time, and his brother is only able to go out for short trips to the grocery store, which he recognizes still poses a safety risk by leaving Alan alone. They have a 2 story home, good DME setup, and some rare support from friends (no remaining family).

Patient “Betty” is a very pleasant woman, always smiling, happy and friendly. Her daughter is a retired pediatric nurse, but is frustrated with herself for not knowing more about geriatric care. She noticed a cough developing earlier in the week but did not expect that illness would cause such a drastic change in her mother's personality and abilities. Normally Betty is able to walk w/o device and perform ADLs with supervision. However, Betty is very afraid of falling in the hospital environment, actually fighting the transfer, and requires max assist of 2 for chair to bed. She is still able to follow 1 step commands as long as they are not about transfers. Betty's daughter is well educated on devices, but has a bad back and cannot lift >10 pounds. Per pt's daughter, Betty did well in rehab previously after a hip replacement.

Patient “Carol” is lethargic and minimally responsive during the evaluation. She responds best to her daughter, and will follow 1 step commands from her. She has severe retropulsion in sitting. I could not transfer her, but her daughter was able to in a less than fully safe method. Daughter reports that there are multiple family members that live in the home with Carol, and others that assist in rotating care duties. They have good DME setup at home and 24 hour assist with various caregivers. Carol clearly responds best to her family members over the staff at the hospital.

Who gets to go where? There are few hard and fast rules in discharge planning. Because OT is committed to being client and family-centered (and because care for a person with moderate dementia requires a high level of commitment from the family), discussions regarding each option were provided to the families of the patients. These are the decisions we made together, though it is certainly possible that other therapists or case managers may have tried to elicit a different response.

Alan was recommended for a trial of inpatient rehabilitation at a subacute level to attempt to progress in ADLs and transfers. The plan was to select a facility that also provides long term care, as Alan's brother could no longer care for him at home. Special consideration was given to make this place close to their home so that Alan's brother could make frequent visits.

Betty was recommended for inpatient rehab at a subacute level at a facility she had been to previously. Betty's daughter would not be able to care for her currently, but was open to the idea of family training and purchase of lifting devices if needed to allow for her to return home after rehab. She also had a good connection with home therapists as well.

Carol was recommended to return home with home health therapy to address safety in transfers and additional adaptive equipment assessment for best safety at home for her and the family. She was unlikely to fare well in any facility cognitively or with physical progress. The family was ready to continue 24 hour assist and try whatever was necessary to provide for Carol.

Discharge planning is not always easy. Therapists, MDs, case managers and the family do not always reach agreement. But this was a situation where even though there were difficult decisions, each family unit got what was best for them, I think.


Diandra said...

Cheryl, I am so glad you blog... I have a feeling you may write text books one day :)... I deal with these types of patients daily, and this was such a clear way of explaining and rationalizing. You are an OT rock star! :)

Cheryl said...

Thanks for the vote of confidence DeeDee- I'll figure out what to do with myself someday :)

Gholc said...

As an OTA student doing my field work 1 at an SNF, I have some appreciation for how difficult these decisions must be. At the facility where I am doing my fieldwork, about half the patients are rehab and about half are residents. It is interesting how much of the discharge decision is based on the situation at home. Two of your three patients could not go home because their caretakers could not care for them. At the SNF they are not generally under the same time constraint; however, the same concerns are discussed. One patient, recovering from C -Diff, lived alone in a trailer with three steep steps to the front door. She could not be discharged until she was independent in ADL, IADL and she could manage the steps. Given her frail medical condition, this has meant a fairly long stay in the SNF. A person in her condition with a willing and able caregiver might have been discharged sooner. I think this is an interesting topic, thank you for writing about it.