Hospital Discharges are like Expeditions to Antarctica: Be Prepared

Ernest Shackleton’s recruiting advertisement has become the stuff of lore:

Men wanted for hazardous journey. Low wages, bitter cold, long hours of complete darkness. Safe return doubtful. Honor and recognition in event of success.

When considering the hospitalization of older adults, families should realize they’ve effectively signed on for an Antarctic expedition.

Here is my Shackleton-esque ad for a hospitalization of an older adult:

Patient wanted for hazardous confinement.  Needle sticks, poor sleep and periods of fasting required. Novel exposures to resistant pathogens and potent medications ensured. Must be able to navigate self-care in diminished state or utilize vast resources to receive assistance after conclusion.

Millions of older people enter the hospital each year for elective treatment of serious medical issues such as cancer, heart disease, and quality of life surgeries like joint replacement. While a successful hospitalization is almost entirely determined by prior planning, so few people walk in prepared to leave.

Planning a Hospital Discharge

As a physician advocate, I frequently get urgent calls about hospital discharge crises. I understand the panic, because hospital discharge is one of the most important moments in a patient’s care journey and is fraught with danger.

The experience of hospital discharge, either to home or another health care facility (such as a Skilled Nursing Facility or Rehabilitation center) often seems rushed and quite quickly, care is no longer tethered to established payment mechanisms. This leaves patients and families feeling very very stressed.

There will be over 10 million hospital discharges each year for people over the age of 65 for the foreseeable future. This is a set up for millions of miscommunications, errors and oversights. For example, one study showed that nearly 20% of patients experience an “adverse event” after hospital discharge such as medication mix-ups, hospital-acquired infections and procedural complications. A more subtle danger is the lack of follow-up on important diagnostic tests leading to missed diagnoses.

Millions of people enter the hospital each year for elective treatment of serious medical issues such as cancer, heart disease, and joint replacement yet few are prepared for what comes after.

Some of the things that are important to think about when leaving the hospital are:

1. Do you have a new list of medications? How does it compare to the medication list before hospitalization? Which medicines should be discarded?
2. What are the potential complications from any procedure you underwent? What should you return to the hospital for? How can you reach your doctor for any questions about symptoms or difficulties when you are home?
3. Know when and with whom you need to follow up. Were referrals made for other specialists? When are those appointments scheduled? Do you need to make the appointment?
4. Do you need a Nurse, Therapist, Home Health Aide or any Medical Supplies at home?
5. What were you able to do before being admitted, what are your anticipated care needs now? How long will you need extra help?
6. What post-hospitalization care is covered by your health insurance? What conditions are attached to payment? Is hospice care needed?

More and more, families will be responsible for what happens after a hospitalization, especially when the destination is home. As a recent Wall Street Journal article noted, although home health is covered by some insurance, nearly 70% of patients had NO home visit from a nurse or other healthcare professional after hospital discharge. Thankfully, that’s changing along with other efforts to reduce hospital readmissions.

Post-hospitalization care at home may be more than many families can muster on their own, so those that can afford private duty nursing services may choose it after hospital discharge. Before committing to pay for a private duty nurse, it’s important to check with your insurer to see if any Home Health services are covered (some are even covered by Medicare).

In addition, while our advance directives focus primarily on what kind of medical care we wish to receive IN the hospital, too few people take the time to outline the kind of care they want to receive after they leave. Even fewer specify what kind of financial arrangements (such as long-term care insurance or savings) they have made for their spouse or offspring to access when they need more care after an illness or surgery. 

I’ve developed an abridged Advance Care Plan for people who expect to be in the hospital. This document can be vital for a spouse, adult child or anyone who is making critical decisions about your care, whether from a quality of life joint replacement or a life-threatening cancer. This DOES NOT replace your Advance Health Care Directive, but you should attach it to your legally signed Directive. Also, don’t forget to give your health care proxy a copy of your Insurance or Medicare card. You can download the Advance Care Plan here, fill it out on your computer and print it up.

Recall, with the right recruits and preparation, Shackleton didn’t lose a single man.

A word of caution: printing something up and filing it away isn’t enough. Discussing your hopes and goals for an elective procedure and a considered plan if things don’t go as expected is what it takes to embark on a medical expedition. Recall, with the right recruits and preparation, Shackleton didn’t lose a single man.

---