Will you be ready when you leave the hospital?

Medical Matters

Staying Healthy

December 30, 2005|By JUDY FOREMAN

Modern American medicine does many things exceedingly well, but helping patients leave the hospital is still not one of them. They're sent home still groggy from drugs and in need of assistance -- though they don't always have it.

"In the hospital, the bathroom is close by, there are no stairs, food is brought to you, medicines are brought to you, your health status is checked on a regular basis," said Andrew Dreyfus, executive vice president of Blue Cross Blue Shield of Massachusetts. "Suddenly, when you go home, that structure is removed."

Sharon Postma, 48, a Boston resident who teaches fifth grade, became an unwitting expert on this topic last summer.

Postma had an emergency hospitalization for a kink in a ureter, a tube that carries urine from the kidneys to the bladder. When she was discharged, a friend dropped her off at home, still woozy on pain medications.

"I should have had someone stay overnight, but I didn't," said Postma, who lives alone and spent her first night home drugged and feverish.

When she had to go back for surgery a few months later, Postma arranged for a friend, Mandy Waddell, to stay the night.

The experience, for Waddell, was eye-opening: "Hospitals sometimes seem to treat everyone as though they had family to go home to. They try, but they don't always take enough into account those of us who live alone and may not have help."

About 28 percent of Americans now live alone, according to the Census Bureau, with no one on hand to help decipher pill bottles, cook dinner or even negotiate the route from the bed to the bathroom.

Discharge planning is such a problem that, in August, the Joint Commission on Accreditation of Healthcare Organizations, the group that accredits hospitals, launched a new campaign to help patients negotiate the hospital-to-home transition. (To see its brochure, "Planning Your Recovery," visit jcaho.org and look under "Speak Up.")

"In any industry, the point where there is a hand-off of information is a risky period," said Dr. Peter Pronovost, a patient care expert at the Johns Hopkins School of Medicine.

But the handoffs are especially difficult in health care "because of the way we pay for health care -- it's highly fragmented," said Dr. Don Berwick, chief executive officer of the Institute for Healthcare Improvement, a nonprofit advocacy group.

"Transitions don't go well because patients are moving from one `silo' to another," from the hospital's care and billing system, back to their own doctors, home health aides or others who are billed separately. It takes time, energy, and often a team of social workers to set up and arrange payment for services at home.

Given that it will likely be years, if not decades, before somebody figures out a better system, I humbly offer my own guide for the newly discharged.

Most important: Be proactive, early and often. If you are likely to be discharged to a rehabilitation facility or a nursing home, check out two or three places before your hospitalization, or have a friend or family member do it. You often have a choice.

If you expect to go home soon after an operation, "The time to start talking about what you will need afterwards is in the surgeon's office when you're talking about the surgery," said Dr. Michael Gustafson, vice president for clinical excellence at Brigham and Women's Hospital in Boston. Not when you're lying in the hospital bed feeling terrible.

With orthopedic procedures, for example, some hospitals, including Brigham, will send a nurse or physical therapist to your home before the surgery to check things such as whether you'll need to move furniture, or how many stairs you'll have to climb.

If it's an emergency procedure, obviously, it's harder to plan, but now's the time to call in favors from friends.

Then there's the awkward business of getting medications for a homeward-bound patient. Do you leave your pale, exhausted spouse or friend in the car while you run in to the drug store? Or do you take them home and leave them alone while you dash out again?

Some hospitals, including the UCLA Medical Center, now have on-site, outpatient pharmacies to minimize this hassle, said Dr. Tom Rosenthal, chief medical officer at UCLA. Another solution is to ask the hospital to fax your prescriptions to your local pharmacy so the medications will be ready for quick pickup on your way home.

The good news is that hospitals seem to be getting better at providing discharge instructions -- in fact, they have to by law, said Leslie Kirle, senior director for clinical policy and patient advocacy at the Massachusetts Hospital Association.

Your job or that of a friend or family member, is to "read it before you leave, and ask a doctor or nurse to go over it with you to make sure you understand it," said Stephen O'Neill, social work manager for psychiatry and primary care at Beth Israel Deaconess Medical Center in Boston.

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