Special teams help shorten hospital stays Field spawned by effort to cut costs

August 03, 1993|By Wayne Hardin | Wayne Hardin,Staff Writer

A dying patient wants to spend one last holiday with her family. A man puts beer in his feeding tube at home. A woman can't be discharged from the hospital because she is not a U.S. citizen.

The problems vary widely but the people have one thing in common. All are patients facing difficulties that go well beyond the illnesses or accidents that brought them into hospitals.

Coping with their needs is a group of hospital employees whose role has grown along with the pressure to discharge patients much more rapidly than in the past. The field began taking shape in the early 1980s, as a result of a movement to cut medical costs by shortening stays.

The group is made up of trained social workers, nurses and other professionals whose task is planning patients' discharge from hospitals. Their work, which remains largely unknown to the public, also involves compassionately listening to patients and interceding with insurers and even with relatives.

"Today, patients coming into hospitals, by and large, are sicker," says Geoffrey B. Barnes, 46, administrator of the Sinai Hospital departments of social work and psychiatry, and a social worker since 1969. "They have more psychological, social and emotional needs than ever before."

Krystal Tripp, 33, a social worker at Greater Baltimore Medical Center, tells of a Baltimore County man whose craving for alcohol was nearly his undoing.

The patient, a 75-year-old bachelor, had suffered a stroke that prevented him from swallowing. He lived alone but was taught how to manage his feeding tube. A few months after he went home, a neighbor who had agreed to monitor him told the hospital the deal was off.

"When he came back to us, he was bedridden and he had bedsores all over his body," Ms. Tripp says. "We found he had been pouring beer into his feeding tube. He couldn't taste it any more but still liked the feeling the alcohol gave him.

"Most cases -- after evaluation -- involve a social worker or a discharge planner. This one took both."

Staffers arranged a special bed, physical therapy and a skilled nurse to monitor the tube. They obtained adult protective services through the county, found housekeepers and persuaded the man's brother and sister to take a greater role in his care.

"We told him, 'To stay at home, you have to agree to certain things,' " she says. "It was give and take. He wouldn't say he'd never have a beer, but he agreed not to have five or six at once."

The man still is home and "living up to his agreements," Ms. Tripp says.

Social workers, who must have at least a bachelor's degree in the subject and be certified and licensed by the state, enter the lives of hospital patients almost immediately.

"In the old days, social workers were an afterthought," says Frank Monius, assistant vice president for planning with the Maryland Hospital Association. "Today, the social worker is thought of right from the beginning."

Swift notification at Franklin Square

At Franklin Square Hospital Center in Baltimore County, the Department of Social Work is notified as soon as a patient checks in.

"We start practically on the day of admission to formulate a plan for the patient's discharge," says Bea Grossfeld, director of the department and immediate past-president of the Maryland chapter of the Society of Hospital Social Work Directors.

"Families aren't ready for that," she says. "They can't conceive of a patient being in bed only one day and the social worker is talking about discharge. But we have to begin as soon as possible to ensure a smooth transition."

After release from the hospital, a patient may go to a nursing home or rehabilitation center. If able to return home, a person may need skilled nursing assistance, home health aides or adult day care. For people who are dying, hospice care may be preferred.

But arrangements seldom are simple.

Patients may live alone or come from families whose members are widely scattered.

Sometimes the elderly outlive their children. Certain types of nursing-home beds may be in short supply. Complications often include finances, insurance, transportation, even language barriers.

Sinai, for example, serves large numbers of Russian Jewish immigrants. "Many don't speak English. We have to get an interpreter in," Mr. Barnes says. "Then, you have to think about the implications of discharge planning. How would a nursing home care for such a patient? An interpreter around the clock?"

In fact, Sinai, which has two full-time Russian interpreters on staff, has identified at least three nursing homes in the area that provide interpreters.

Untangling the red tape

At times, discharge planners and social workers go to great lengths to untangle red tape.

It took eight months to arrange the discharge of one woman from the University of Maryland Medical Center in Baltimore.

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