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Discharge Dilemmas 

The discharge process at hospitals can be confusing for patients and their families

Ideally, once you leave the hospital — lollipop in hand, Daffy Duck band-aid on your arm — you’re “all better now.”

Not quite.

The road away from the hospital towers is bumpy, winding, and full of potholes. If there’s miscommunication, if discharge occurs at the wrong time or without the proper support services and education in place, major problems can arise.

Donna — who asked her last name not be used — has seen what can go wrong. Her mother, who has bipolar disorder, was admitted to a local hospital with a urinary tract infection a few years ago. The doctor told Donna her mother wasn’t going to be released until after the weekend.

But when she came to visit her mother the next day, another doctor — one she hadn’t seen before — announced her mother was, in fact, going home that day. Donna was stunned. Her mother, she says, was clearly weathering a bipolar episode: She was attempting to redecorate her hospital room. She wasn’t ready for discharge.

Donna had no idea where the staff planned to send her mother, or when they planned on telling her — her mother’s legal guardian — about the sudden change in plans.

At Sacred Heart Medical Center, Case Management Director Pete Kleweno’s goal is to make sure that sort of miscommunication doesn’t happen.

In Kleweno’s office, nestled in the white-walled labyrinth of Sacred Heart Medical Center, his bookshelf is filled with thick binders — sheaves of rules, records and regulations.

Clad in a gray suit and glasses, Kleweno announces something you’ve probably long suspected: Medicine is complicated. And it’s growing ever more so. Kleweno’s the one who helps untangle the knots and solve problems.

“Doctors [often] don’t understand the rules very well, and they depend on my department to help explain it.” Kleweno says. He finds answers to the tricky questions: When should patients be discharged? Should they go home, to rehab, to an assisted living facility or to a nursing home?

Almost always, the answer is, “It depends.” It depends on the illness, on the severity, on a family’s living situation.

It can sometimes also depend on who is paying and how much they’re willing to continue to pay.

“I think that, because of insurance pressures, patients are being discharged ‘quicker and sicker’ than they have been before,” worries Bonnie Lawrence, communication manager for the Family Caregiver Alliance.

Becky Tiller, president of Tiller Care Strategies, says she’s also seen patients discharged too quickly or into an unsafe environment.

“You have this vicious cycle of people discharged way too soon, and so they’re repeat customers,” Tiller says. Her company offers services to check out the patient’s post-discharge living situation in person, in order to customize it for the patient’s needs. Tiller hopes to help shrink the readmission rate.

While hospitals don’t have the time or manpower for such in-person inspections, Kleweno says they ask a series of questions: Do you have stairs in your house? How many? Do they have handrails?

“We try to be very concerned… Is the patient going to be safe on discharge?” Kleweno says.

Kleweno says the discharge process at Sacred Heart is not connected to the patient’s finances. He says the hospital employs a checklist of objective health criteria to determine whether a patient’s ready to leave. Patients may protest discharge if they feel unready by submitting a petition to Qualis Health, a nonprofit quality-improvement organization, for a second opinion. These and other patient’s rights are repeatedly delineated, in writing, to the patient and their family.

“It’s almost like buying a car to get out of the hospital, there’s so much paperwork,” Kleweno says.

And, like buying a car, patients and their caregivers need to be diligent regarding the patient’s needs. Ronda Stowe, therapy manager for St. Luke’s, emphasizes that constant questioning from everyone involved is vital for a successful recovery.

“There are certain generations that don’t ask questions,” Stowe says. Too often, she finds the elderly simply accept what the doctor tells them — because the doctor is the doctor — instead of probing deeper.

Lawrence agrees. “Ask a lot of questions. Try to get the answers on tape or in writing. They’re going to run a lot of information by you very quickly,” she says. “You have to be as persistent as you can in getting the answers.”

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