PCMW

Length of stay for patients is a topic I feel has been addressed in the wrong light, and I would like to approach it from a different angle.  I have come up with what I like to call the 3-day Rule.

It appears to me that after 3 days in the hospital it becomes increasingly difficult for patients to be discharged, and patients begin to have an increasing number of difficulties that are not related to their admitting diagnosis.  I know the obvious answer to this is the patient is in the hospital longer due to their complicated illness, but I am stating that a lot of the time more complications arise due to the longer length of stay.  There are several causes of the increasing problems.

After a few days in a hospital patients and their families tend to start searching for illnesses that are not there.  Anxiety starts to take over and they imagine they are sick.  This undue anxiety becomes a roadblock to the patient’s care.  It becomes increasingly difficult to keep the patient focused on the issue at hand and this makes it harder to build a treatment plan with the patient for the condition they presented with.

The less focused they become the more emotional patients and families become.  Once people become overly emotional about their healthcare it is harder to refocus them to the necessary treatment plan and keep their healthcare moving along outside of the hospital.  They become more dependent on the high level of attention and care they get in the hospital and see it as the only place they can get “fixed”.  Patients and families need to realize they get diagnosed in the hospital and they recover at home or in another facility.

Also, there is one of my favorite sayings, “The longer you stay in the Hospital the more likely it is you will get sick.”   There is a very real risk of Hospital acquired infections that are especially dangerous for immunocompromised patients such as the elderly, folks with cancer, COPD, and many others.   The longer these patients stay in the hospital, the more this risk increases.  It is much better when possible and safe that these high-risk patients continue their treatment and recovery outside of the hospital.

Then there is the problem of medical fishing.  The longer patients stay in the hospital it becomes more likely that there is an increasing number of consults.  There then are an increasing number of tests ordered and treatments being given.  The patient’s care begins to be more fragmented.  It starts to be unclear as to what exactly the patient is being treated for, which in turn adds more days to their inpatient stay and begins to create issues for the patient that it is not necessary to treat at that time.

It is not always the best thing for patients, to overly analyze what is going on with them to create answers for issues that are non-issues.  This again causes the patient undue anxiety, and puts an unnecessary burden on the patient, their family, and the hospital that is providing the unnecessary healthcare for them.  Sometimes we need to be comfortable telling people that regardless of their presenting symptoms there is simply nothing wrong with them at this time.  If you search long enough you will find something wrong with just about anyone, but that is not really a good thing most of the time.

A large majority of illnesses that people present to the hospital with can be treated within 3 days.  From strokes to heart attacks most patients do not need to be in the hospital longer than 3 days, and I would argue it is bad for them to stay longer than that.  It is not always easy to provide the appropriate amount of care for patients with all of the pressures from families, consultants (to get used more), and also fear of lawsuits.  However, it is necessary to provide the best care for the patient, and when I look at this problem the answer seems clear that most of the time the best care for patients is provided within the 3-day Rule.

Sometimes at a hospital you need the ability to recognize things that are out of your control, things you cannot change, and things you cannot do.  A great line I have heard countless times from my boss and a mentor is, “It is what it is.”  We have heard him say this so much it is almost a joke for us to quote it.  However, these words and this frame of mind can be the difference in keeping your sanity in healthcare.

It is important to realize when there is nothing you can do about a situation.  Whether it is waiting for a state run facility to accept a psych transfer, waiting for an insurance provider to give you a last minute authorization at 3:30 PM on a Friday afternoon, or waiting for 15 family members to make a decision about a care plan; sometimes you just can’t force something to happen and you have to step back and let the situation unfold on its own.

Stepping out of the situation is sometimes what needs to happen for a solution to arise.  (Personal disclaimer:  I am not very good at this!)  We have a mindset in the hospital that we must always be in control of things.  You can still be in control of a situation while doing nothing and letting it resolve while standing aside for a moment.  Especially when working with families, this can be very empowering for them and is often the control they need to come to a decision.

This mantra is also very important when setting expectations for patients and families.  It is important to always set realistic expectations of services available and potential for recovery for patients.  It can be more harmful than good to hand a list of all nursing facilities available in an area to a patient with no money or insurance and ask them to choose from it when 99% of them are not attainable options for them.  It is also more harmful than good to allow a family to retain false hope about a patient’s potential for recovery.

Establishing realistic expectations for a family and patient is the basis of a solid working relationship with them.  This needs to be established early in the treatment planning, as the longer false expectations linger the harder they are to change.  Being upfront, open, and honest about what you can provide a family and why the options are what they are is the only way to provide good care for a patient and their family.  We are here to explain to a patient and family what is going on with their care, not to let them find out on their own.

The constant battles of everyday work in a hospital can be very taxing emotionally and physically, so it is important to fight battles that can actually be won.  Some things cannot be changed and even though it may be hard to accept, it is what it is.

“If it’s not documented it never happened.”  I have heard this quite often at work.  I also recently had the pleasure of this being proven first hand by attending a deposition.  Anything I had not documented didn’t matter, and also I wouldn’t have remembered it anyway.  The only thing that proves we do our jobs as case managers is that we document it thoroughly.  There are several reasons it is important we document aside from the fact that it proves we are working while at work.  I will touch on one with today’s post and continue with more in later posts.

Our documentation is the most reliable way to communicate with the other healthcare workers seeing a patient.  By documenting our contributions to the patient’s care, we allow others to see what we have done and formulate continuing care plans with that in mind.  This is important when using a proactive approach to discharge planning.

By documenting early and often on a patient you establish yourself as a prominent part of the patient’s care team.  You also help to shape the care of the patient and keep that patient’s care moving along efficiently.  It is important in building a relationship with the patient as well as building a relationship with the others involved in that patient’s care.

It is important to keep open lines of communication with everyone involved in the patient’s care.  Your documentation is one way to do this, and it also serves as a reminder of your earlier conversations with others seeing that patient.  There may also be different people serving that patient from day to day and it serves as a tool for continuity.  Even if you are not doing new and different things on a daily basis for a patient it can be very helpful to reprint your note regularly so it does not get lost in the chart.

If you are going to remain an integral part of the patient’s care team throughout their stay you need to keep your documentation prominent and recognizable.  Always document in the same style, in a very simple and direct format, and on a regular basis.  Point out your documentation to people and guide them to it for information.  Once people begin to expect this from you, they will begin to notice and even look for your notes.  They will become a useful tool for the entire care team, and help you remain intricately involved with the team.  Your documentation will become consistent communication throughout the patient’s care.

Spending this week starting a new program at a new hospital I found myself focusing on time management tools I have learned .  One of the most important ones we can use is what I like to call directed conversation.

Prior to approaching a patient or family with discharge planning you need to carefully plan your meeting with the patient.  You must have a goal for the meeting that best suits the patient’s needs and care plan and use this goal to plan a path of conversation for the encounter.  This goes beyond simply knowing the purpose of your meeting (e.g. Nursing home placement, etc.).

Playing through the possible conversation in your head prior to the actual encounter will increase the efficacy of the meeting and your ability to be useful in guiding the patient’s care.  It will also limit the opportunity for you to be stumped by questions from the patient and family.  It is important when dealing with patients and families to always have an acceptable answer to all of their questions.

It is also important to not let conversation stray away from the topic at hand.  The best way to do this is to limit the number of variables you allow into the conversation.  If you are talking about in patient rehab the patient’s care at home is not relevant at this time.  The Case Manager is responsible to help the family narrow their focus to what truly matters at this particular time for the patient’s care.

What makes this possible is remembering that each Case Management encounter for discharge planning must answer the same basic questions, but they do not need to be asked the same way each time.  If you personalize the conversation it makes it easier for you to keep the conversation moving in a productive manner toward your end goal.

You can accomplish this personalization prior to entering the room by discussing the family and patient with nurses and doctors who have met them so you know what you are walking into.   Just as you review the medical chart before meeting with a patient, it is important to know about them socially.

In the end what we are doing is “selling” a treatment plan to people.  In doing this we need to appear confident and have a concise plan to present to the patient and family when meeting with them.  If you are thoroughly prepared for the encounter and engage in directed conversation the discharge planning process will be much more effective and time efficient.