Learning Objectives:

Knowledge - Students should be able to describe and define:

• High risk social and medical discharge indicators ( Appendix 1 )
• Discharge levels of care ( Appendix 2 )
• Community resources that address discharge needs
• Role of the physician in the discharge process

Skills - Students should be able to demonstrate the following skills:



History taking:

• Obtain information that identifies high risk discharge indicators
• Assess physical and mental functioning required for ADL (activities of daily living) ( Appendix  3 )
• Obtain information to assess support system

Differential Diagnosis:

• Differentiate the facility levels of care from home care service needs
• Communication: ( Appendix 4 )
• Discuss with the patient and family the realistic recommendation for a specific facility level of care and/or home care service. Respond to the questions and
  concerns of the patient and family regarding the need and utilization of the recommendation.
• Collaboration with other professionals and appropriate agencies.

Attitudes and Professional Behavior

Students should:

• Be aware of the issues related to making an appropriate decision regarding care post  hospitalization and sensitive to the impact this decision has on the patient and family.
• Recognize the role of realistic community resources in discharge planning.
• Recognize need to collaborate with Social Work and other professionals in the decision-making process in a timely fashion.
• Recognize the impact financial resources has in discharge planning, i.e., access to
  medications, physicians, therapy, etc.

DISCHARGE HIGH RISK INDICATOR* (APPENDIX 1)

Return to Knowledge

AFTER DISCHARGE LEVELS OF CARE: (APPENDIX 2)

Sometimes it is necessary to continue your recovery with services provided at home or in a specialized facility. These services may include:

If your doctor recommends follow-up home care, hospice or rehabilitation services, a social worker will assist you with the referral at that time.

The above listed facilities are regulated by federal and state agencies. A list of home care agencies in your area is available and will be provided by the social worker and/or nurse on request.

Return to Knowledge

History Taking & ADL Assessment Guide (APPENDIX 3)

1. Mobility: Walking Set-up of Home?

Sitting Steps
Range of Motion Bathroom
Assistive Device Telephone

2. Perception: Consciousness/mental status oriented to time

Vision
Hearing
Sleep
Pain

3. Activities: Meals How do you spend the day?

Transportation
Child Care
Food/Shopping/Personal Care

Any agencies involved?

Family/Support System:

Who is available to help?
Family/Friends?
Any cultural reactions that need to be part of patient's care?

Return to Skills

 

 

Communication Hints* ( APPENDIX 4)

How to Engage Your Patient

PREPARATION: Helping yourself to be ready, cognitively and effectively, to give help.

Tuning in, or putting yourself in the client's shoes.
Tuning in to oneself: what this client or problem stirs up in oneself. Possible other concerns which need to be set aside in order to present to this client.
Tuning in to context: impact upon both of you of this agency services, policies, ambiance,
broad social issues, or other factors.
Reviewing prior contacts with oneself or other helpers, records, etc. (Sometimes a decision is deliberately made not to review records before first session, to avoid prejudging the client.)
Considering potential foci and purposes of meeting from your point of view to be re-evaluated upon meeting client.

CONTACT: Helping applicant become a client.

Communicating caring, concern, interest
Offering clarification and structure
Making a clear statement of agency function and your role
Trying to help client feel comfortable
Asking each client about his/her concerns

EXPLORATION: Helping the client tell his/her story

Communicating accurate empathy interest in how client might be feeling, as well as facts and events; everyone s perceptions and experiences in multiple person interviews
Asking questions which encourage elaboration
Keeping interruptions of the client s spontaneousness as few as possible (unless a torrent of words and feelings, which need limits)
Enabling people to talk to each other
Searching to understand client s personal and cultural ways of communicating

CONTRACT: Helping the client engage with you in working together

Restating and summarizing your understanding of the problem
Expressing your contract using client s unique language
Offering hope and resources
Eliciting client s ideas on how you can work together
Partializing and prioritizing needs and concerns
Identifying next steps and allocating tasks
Planning next meeting time, etc.

*Source: Simmons College School of Social Work, Clinical Practice I Summary of article entitled, Patient and Family Satisfaction with Discharge Plans by Proctor,
Morrow-Howell, Albaz and Weir. Medical Care, March, 1992, Vol. 30, #3, pp 262-275.

Return to Skills

WORKSHEET

(for all answers)

Summary/Conclusions:

This study explores various factors, which affect patient and family satisfaction with discharge plans. It defines discharge planning as an inter-disciplinary, hospital-wide process that should be available to all patients. It is important to evaluate consumer satisfaction because: 1) we must comply with Medicare's perspective payment system; 2) efficient use of continuum of care services will decrease costly re-admissions; 3) documentation of reasonable discharge efforts
protects the healthcare industry legally and; 4) discharge planners can impact patient and family satisfaction through their close contact. Increased patient satisfaction with discharge plans contributes to continued use of the hospital system s health services, decrease in malpractice suits and increased compliance with regimens.

Primary conclusions of this study are as follows:

Patients have more person-oriented concerns, such as their ability to function and who will provide their care. When these concerns were addressed and patients were involved in the decision-making process, their satisfaction with the discharge plan was increased.

Families have more process-oriented concerns, such as amount of time spent by discharge planner on their case, the number of options considered, and the involvement of the patient in decisions.

The implications of the above are that health professions can increase patient/family satisfaction with increased communication and relationship-building interventions which involve empowering patients to make decisions and being sensitive to their feelings and concerns.

It is not surprising that patient/family satisfaction was lowest when the discharge was to nursing homes; however, the study indicates that even here, the Social Worker can impact satisfaction by spending more time, increasing professional attention and demonstrating that we have undertaken
a thorough planning process on the patient s behalf.