The Foglight - Leaving the Hospital, Part 1: Leaving to Go Home

November 2023

Issue # 5 November 2023
In This Issue: Hospital Discharges, part 1

Dear Reader,

The transition from hospital to home can be tricky. The American insurance system incents hospitals to tightly manage the amount of time a patient stays in the hospital. Patients are expected to go home when they no longer need the bells and whistles of a hospital, which is before they have recovered from their illness or injury.

Hospitals stabilize, diagnose, and adios. Discharges can feel, and sometimes are, abrupt. It can be an intimidating situation. Please read on for part one about leaving the hospital to go home.
 
 

Leaving the Hospital to Go Home, Part 1

I’ve written a lot lately about the difficulties patients face in today’s hospitals, where the patient’s family doctors seldom see their patients, and decisions are often made by the “doc of the day,” a hospitalist with no context and knowledge of the patient. Today I’d like to focus on another kind of difficulty, one that a patient might face not in the hospital, but when leaving the hospital to go home. The transition from hospital to home is far less discussed, but it can be as fraught, with as many pitfalls as the time spent in the hospital. 

Let me tell you a story. It’s a true story, albeit one with some details changed to protect people’s identities. It’s the story of a man in his seventies. He was widowed and lived alone. He was admitted to the hospital after a fall; he was bruised, but nothing too serious, except for severe back pain that had gradually improved.

While he was in the hospital, it was discovered that his diabetes was not well controlled. He now needed to start insulin. During his brief hospital stay of three days, the nurses did the insulin injections for him.

Then, at four o’clock in the afternoon, the new hospitalist finally showed up. It’s likely that he had been having a tough day and was trying to finish up his checklist on his less ill patients. When the hospitalist came in, my client called me immediately, something he’d been doing every time any doctor came into the room. He wanted me to listen in and then tell him what the doctor meant.

The doctor came in, spoke briefly to my client, and told him he was ready to go home. My client immediately went into a panic. “I don’t know how to do this,” he said, referring to the insulin injections. What’s more, he said, he didn’t feel like he was set up to go home in the evening. He wasn’t sure there was enough food in his house, he didn’t feel up to going to the pharmacy, and he wasn’t even sure if he needed help getting around. He was being sent home with no support network in place. 

I was very worried about his ability to do his insulin injections. He’d never drawn up the insulin or given himself an injection, something that made him squeamish. Also, his poor blood sugar control hadn’t happened in a vacuum. He needed education on what to eat.

As the doctor talked over my client and told him he’d be fine to go home, I heard my client fold. After initially pushing back, my client started to say, “Okay, okay.” He felt he had no choice but to obey the harried doctor.

I spoke up and pointed out to the hospitalist that his patient had never given himself insulin, and that he lived alone. The doctor scoffed. “Oh, he can do it,” he said, in a blasé tone. He refused to change his discharge order. 

After the doctor left, I called the discharge planner. I explained that I didn’t think an evening discharge would be safe. She simply said, “Doctor’s orders!” and told me he had to leave. After talking with me, my client decided to stay put and refuse the discharge.

Here’s something many people don’t know: Medicare patients can appeal discharge orders, and when they do, they usually win. I knew that, so I recommended that he appeal the discharge order to Livanta, the contractor that Medicare uses to review patient records. In this case, Livanta agreed that the patient needed more time in the hospital, and overruled the doctor’s order.

My client stayed another 16 hours in the hospital, during which he correctly drew up and gave himself insulin at dinner and then at breakfast the next day. He felt better. The diabetes educator came around and gave him meal ideas and set up outpatient appointments.

Now my client felt like managing his diabetes with insulin and a better diet was feasible. It was more likely that he would get his blood sugars under control and less likely that he’d give himself the wrong dose of insulin. In the meantime, his family and I were able to get support in place for him at home. 

What are the lessons here?

First, in today’s profit-driven world, it’s not just patient’s hospital care that suffers, but even their transition out of the hospital into the home. A patient who received excellent care in the hospital can suffer relapses or new illnesses if the transition to home care is not handled properly.

Second, you can fight back. You can appeal decisions to discharge a patient prematurely.

Third, there are steps you can take, without the doctors or hospital, to make the transition to home smoother and safer. And that’s what I’ll discuss next time!

Dr. Gerda Maissel, MD CPE, BCPA

Dr. Maissel is a Board-Certified Physical Medicine
and Rehabilitation physician
and a Board Certified Patient Advocate
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