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Health care services are becoming more integrated
Experts see greater unity
In some ways, the direction health care is heading could be seen as a back-to-the-future scenario.
Discharge planning may return to its roots as a team process.
"Years ago, when I started out, we worked as a team and met once a week to discuss discharging patients," says Elizabeth J. Clark, PhD, ACSW, MPH, executive director of the National Association of Social Workers in Washington, DC. Clark is a member of the National Transitions of Care Coalition (NTOCC) advisory task force.
"We had a nurse, social worker, and sometimes a clergyman," Clark recalls. "That was when length of stay (LOS) was much longer, and you had a full component in the hospital setting."
The discharge team did a good job of returning patients home, she adds.
"Visiting nurses would come in the hospital and meet with us and do a home assessment," Clark says. "Then people would leave the hospital, and their transition was pretty good."
Years of cutbacks at hospitals forced cost-cutting changes, such as putting the discharge planning role on the shoulders of nurses, she adds.
"They decided nurses could do everything, which is unfair to nurses because they have a lot to do," Clark says. "They kept cutting back because of financial efficiency, and that's been a really unfortunate way to focus on good, patient-centered care."
But over time, health care researchers and experts have noticed a trend of patients who are discharged without adequate resources returning to the hospital within weeks. The long-term financial efficiency is compromised by a model in which discharge planning is not a priority.
"I don't think many of us would say it's very efficient to have someone go home today and then be back in the hospital in two weeks," Clark says.
"They don't like to include education and prevention in their efficiency measures," she adds. "But if they don't do a better job of educating the patient and caregiver, then they're not going to be able to stay in the home."
There are models of collaborative discharge planning and transitions of care teams that offer hope, Clark says.
"It's like going back to the future," Clark says. "In my mind, we're going back to the kind of care we used to give, but we're doing it on an outpatient basis instead of an inpatient basis."
What could increase momentum back to preventive care and more focus on the discharge planning process is President Obama's focus on long-term improvements and prevention, Clark says.
"The new president has come out very strongly in favor of prevention, and that's the first time we've heard a president talk about prevention in terms of their mandate," she says. "We have always known how to do good health counseling and prevention, but nobody has ever been interested in it."
Medicare's reimbursement style should be changed to make it easier on patients and providers, as well as to make the process more efficient, Clark suggests.
For instance, one current barrier is a reimbursement system that allows only one provider to be paid per patient per day, she says.
"If you come in to see one doctor in a day, then if you want to see a dietitian, you'll have to come back another day," Clark says. "It places a tremendous burden on the patient."
These types of barriers make it more challenging for health care providers to collaborate.
Another change that could cause care collaboration and integration involves pending health care workforce shortages.
There are workforce shortages in health care across the board, and as those shortages become more critical, there will be more health care integration, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America in Little Rock, AR. Lattimer also is a member of the NTOCC advisory task force.
"I honestly believe our shortages will drive us to unite," Lattimer says. "We see a lot of case management teams where nurses and case managers work together."
And the next push will be to increase the involvement of families and caregivers in the whole process, she adds.
Discharge planning teams will need to improve patient and family education and learn more effective communication strategies, Lattimer says.
Communication issues to consider
They'll have to consider these communication issues, she adds:
What is the health literacy of the patient and caregivers?
Do the patient and family understand medical terms?
Is English their primary language?
Can they comprehend English?
Did we write the discharge plan patient literature in medical jargon?
"There's a significant recognition of what's good communication and how we can develop that," Lattimer says. "The patient and family might never ask questions while they're in the hospital, and then they might miss their follow-up doctor visit and end up back in the emergency room."