Discharge planning, social work, and legal concerns

Question 1

What are the two most important things to consider in determining if a patient can be discharged in terms of general safety?

Answer 1

1. Functional capacity (ADLs)
2. Living situation

Question 2

List the major locations to which a patient can be discharged.

Answer 2

Home

Shelter

Outpatient rehab

Inpatient rehab

Nursing home

LTAC facility

Question 3

When a patient is discharged home, what are some possible services that may be provided?

Answer 3

• Outpatient PT/OT
• DME
• Home Health
• Hospice

Question 4

What services can be provided for patients with Home Health?

Answer 4

• Medication administration (RNs, PCTs)
• Wound care (RNs, MAs)
• PT/OT
• IV care (<3 infusions per day)

Question 5

What must be ordered to see if a hospital patient qualifies for Home Health and to set up the services for discharge?

Answer 5

A case management consult

Question 6

A patient in fairly good health who has nowhere to go can be discharged to where?

Answer 6

• The street
• A shelter

(per the patient’s preference)

Question 7

True/False.

In the inpatient setting, it is our responsibility to prepare safe, optimized discharges for patients, but it is not our responsibility to take care of every little detail and “coddle” the patients.

Answer 7

True.

It is acceptable to give patients some responsibility in setting up outpatient follow-up, securing their medications, etc.

But if you have time and energy or expect the patient will fail, it is better to provide more assistance.

Question 8

True/False.

The advent of quality control and national standards has made most shelters and nursing homes into high-quality, fairly comparable locations.

Answer 8

False.

They are highly variable in quality.

Question 9

For any stable, hospitalized patient with significant substance abuse issues, what can be offered upon discharge?

Answer 9

Rehabilitation services

(inpatient or outpatient)

Question 10

When does a patient qualify for admission to a nursing home?

Answer 10

When they cannot perform their ADLs alone or with the assistance of family/friends

Question 11

When discharging a patient to a nursing home, what are the two broad classifications of care available?

Answer 11

• Custodial
• SNF

Question 12

What care is provided in a custodial nursing home setting?

And a SNF setting?

Answer 12

Custodial: assistance in meeting ADLs

SNF: similar to Home Health needs

Question 13

How much rehabilitation is typically offered in a nursing home providing SNF care?

Answer 13

~2 hours/day

Question 14

True/False.

Both custodial and SNF care are both typically covered by insurance in the nursing home setting.

Answer 14

False.

Custodial typically is not.

SNF typically is.

Question 15

True/False.

If a nursing home patient needs frequent IV antibiotics, then they should be discharged to SNF care.

Answer 15

False.

These patients should go to an LTAC facility.

Question 16

Patients with what indications should be discharged to an LTAC facility?

Answer 16

• Frequent antibiotics
• Ostomy care
• Assisted ventilation
• Etc.

Question 17

A post-stroke patient needs intense rehabilitation. Where should they be sent?

Answer 17

Inpatient rehabilitation (IPR)

Question 18

What is the general indication for discharge to inpatient rehabilitation?

Answer 18

Aggressive care for 1-2 weeks to help patients recover their ADLs

• Patients post-CVA, post-trauma, with critical illness myopathy, etc.

Question 19

What quantity of therapy is provided in inpatient rehabilitation per day?

Answer 19

~3 hours / day

Question 20

True/False.

Inpatient rehabilitation services are often provided within hospitals and by PM&R physicians.

Answer 20

True.

Question 21

When a hospitalized patient has decided to go to hospice, what are the three likely locations to which they may be sent (and what are the prognosis requirements)?

Answer 21

1. Home with hospice (<6-month prognosis)
2. Nursing home with hospice (<6-month prognosis)
3. Inpatient hospice (<1-week prognosis)

Question 22

If discharging a patient who requires close follow-up, how can a provider help ensure that appropriate follow-up will occur?

Answer 22

1. Set up the appointment before the patient leaves
2. Recruit family and/or friends to help as indicated
3. Send the outpatient provider a discharge summary and/or send it with the patient

Question 23

When discharging a patient who is elderly, has low health literacy, has a complicated medication regimen, has poor medication compliance, and/or has poor eyesight, etc., what are some techniques that a provider can use to help increase the odds of proper medication adherence?

Answer 23

• Use closed-loop communication (have them teach back)
• Write down medications with a simple, clear format
• Simplify medication list as possible
• Use the USP pictograms
• Set up Home Health
• Engage family and/or friends to assist

Question 24

Prior to discharge, what can providers do to help a hospitalized indigent and/or uninsured patient to avoid hefty medical bills and pharmacy costs?

Answer 24

• Consult social work for insurance set-up
• Educate patient about GoodRx
• Research local discount pharmacies

Question 25

List some options that exist for aiding patients without access to transportation.

Answer 25

• Televists
• Some insurance companies (especially the public ones) send vans
• Sometimes, specific illnesses receive transport (e.g., dialysis patients)
• Some ride-share apps help with this barrier via services for patients such as pick-up/drop-off, medication pick-up, etc.

Question 26

Are any options available for helping patients who do not have access to a phone?

Answer 26

Some free options via CMS with minutes and data

Question 27

What should a provider do if a patient wants to leave the hospital AMA?

Answer 27

1. Assess capacity
2. Explain the risks and benefits of leaving
3. Have the patient sign an AMA form (a liability waiver)
4. Discharge them AMA

Question 28

Should a provider let a patient without capacity leave AMA?

Answer 28

No.

Question 29

What should an ED provider do if a patient expresses homicidal or suicidal ideation and needs to be kept in the ED?

Answer 29

Sign a PEC

(physician emergency certificate)

Question 30

What form can a physician use to involuntarily commit a patient? How long does it last?

How does the physician then increase the amount of time if needed?

Answer 30

A PEC, 72 hours

→ a coroner must use a CEC (<14 days?);

→ a judge must issue a JC

Question 31

True/False.

If a patient indicates homicidal intent against a specific person, a provider can PEC the patient but cannot break the patient’s confidentiality.

Answer 31

False.

The Tarasoff decision sets precedent for physicians to warn at-risk parties.

Question 32

What set of laws frees bystanders from liability in providing emergency aid to individuals in non-healthcare settings (e.g., at a car accident)?

What stipulation applies?

Answer 32

Good-Samaritan laws;

the care must be reasonable

Question 33

Via what two methods can an email sent from Outlook by encrypted to protect PHI?

Answer 33

1. Type “ENCRYPT,” “SECURE,” or “SAFEMAIL” into the subject line
2. Mark the email as “Low Importance”

Question 34

For a hosptialist, what is the most effective way to ensure a patient’s PCP is aware of any high-risk needs when the patient returns to ambulatory care?

Answer 34

Closed loop communication

Typically through a phone call or email.

Question 35

What information should be communicated in multi-disciplinary rounds with social work, case management, etc.?

Answer 35

1. One-liner on the patient
2. Anticipated time to discharge
3. Barriers to discharge
4. Any social needs