After spending more than half of the last 20 months in a variety of hospitals, all 35-year-old Charlotte White wanted to do was go home. But going home was no simple matter.
A partial quadriplegic with some use of her hands, the result of an auto accident a year and a half ago, she uses a wheelchair, is unable to transfer herself to a chair or bed, and needs a catheter to control her bladder. With two young sons, a husband who often travels out of town on business, and limited home care and day care services in her home town in southern Maryland, she knew that she simply could not manage at home alone.
White, however, did not have to deal with this problem alone. Before leaving Washington Hospital Center this fall, social worker Dudley Warner served as her discharge planner -- the person responsible for coordinating services that will help a patient make the transition from hospital to home. Warner helped White order a wheelchair at reduced cost and arranged for her to go to a rehabilitation hospital in Bryn Mawr, Pa., where her mother lives and could care for her children. Her husband visited her on weekends.
At the rehabilitation hospital, White received the intensive physical and occupational therapy that helped her become independent enough to go home early last month. A social worker at the rehabilitation hospital arranged for help with child care and other supportive services at home.
In addition to organizing support services, Warner helped White and her family cope with the emotional strain of her disability.
"Discharge planning isn't just forms and equipment," says Jim Sayers, director of social service at the Washington Hospital Center. "It's dealing with the family issues that go with the forms and equipment."
In White's case, this included helping her and her husband, Jack, cope with the loss of her independence and their long separations.
"When I kind of got over the shock of the accident and I realized that I had Dudley to talk to and my family had Dudley to talk to, I felt very relieved," White said.
Not every patient needs a discharge planner. But for those who otherwise would be unable to leave the hospital because of complex family, financial and medical circumstances, discharge planning is essential.
More than 80 percent of American hospitals now provide discharge planning, the American Hospital Association estimates.
Discharge planning is not new -- social workers began coordinating patient's return home as early as 1905. But today, discharge planning has taken on a new importance as physicians and hospital administrators face new federal reimbursement schedules that provide incentives to get patients out of the hospital as soon as they can.
"Effective and efficient discharge planning is critical to the health and safety of patients and is important to the hospital from a fiscal point of view," notes the American Hospital Association's new discharge planning guidelines. "If the planning process is not adequate, the length of stay may increase. The patient may be released to an inappropriate level of care, require readmission to the hospital or suffer the loss of gains made during the initial hospitalization." With hospital costs averaging about $475 per day, patient stays longer than the period paid for by insurance could put a serious financial strain on hospitals.
Because of this increased pressure, many hospitals that did not have organized discharge planning departments have, in recent years, hired social workers and nurses to create such programs.
"Ten years ago, you would hear that social work is not a revenue-producing department," says Sandra Robinson, assistant director of social work at Greater Southeast Community Hospital. "But now you don't hear that anymore."
Since the new payment systems went into effect two years ago, she says, "we've seen an increase in the number of cases we have because physicians are more aware of being on deadlines and are referring more."
Traditionally, social workers have coordinated discharge plans because they are trained to look at a patient in the context of his or her community, to deal with the emotional and family issues and to link various community services and resources.
However, as medical and home care become more technical and complex, many hospitals, like Greater Southeast, are using nurses as the primary discharge planners, arranging concrete services (ordering equipment, making referrals to nursing homes and rehabilitation hospitals) and consulting with a social worker when there are serious family and financial problems.
"You cannot operate without a nurse and a social worker," says Margaret Terry, a registered nurse who directs Greater Southeast's community services department. "You have to have someone talk with the doctors and families about the medical nursing needs of patients and someone to talk about the psycho-social needs."
Sometimes the result of discharge planning is that the patient stays in the hospital because an appropriate nursing home or bed in a rehabilitation hospital cannot be found. Other times, although the patient is medically stable, the discharge planner knows that the family could not care properly for the patient at home.
Discharge planners are "a kind of buffer and a safeguard," says Washington Hospital Center social worker Jay Kenney. "Yes, we're concerned about reducing length of stay. However, we have to look at the reality of what exists for this person once they leave the boundaries of our hospital."
Discharge planning becomes particularly complex when a patient's financial resources are limited. Patients who cannot afford to pay for a nursing home bed and are on Medicaid can stay in the hospital as much as several months until a bed becomes available. For other patients, medical insurance often may not cover all the nursing services required for him to go home. Or a patient may not qualify for certain federal assistance programs because his income exceeds the requirement, yet they can't afford to pay for home nursing and equipment. In these cases, discharge planners have to be creative, stretching available resources.
Discharge planners can help make a difficult hospitalization easier to bear. Says Charolotte White: "I don't want to get on the phone [to make arrangements for discharge]. That's where Dudley comes in. I let him do the leg work. He is good at convincing you that you have to have positive thinking -- without that you'd give up. He was sort of rock in the middle of the ocean. You could count on him coming in when you need him."