Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern



Discharge from the hospital has become a rather dangerous proposition.

Given Medicare’s penalties for readmission within the first 30 days, it has never been more important to discharge patients safely and with a solid plan.

Hospital-based medical professionals are at a bit of a disadvantage. Working under time pressure to discharge as soon as it is medically safe to do so, and never having the opportunity to see the patient’s home environment, discharge planners send patients home knowing only what the patient or family has told them.

Those of us who work with patients in the community are all too familiar with the considerable gap that can exist between a patient’s description of their home environment – and their abilities within that environment — and the reality of the situation.

The Ideal Discharge
A safe and ideal discharge revolves around a few key concepts:

  • Determination of the most appropriate post-discharge setting;
  • Identifying what the patient needs for a smooth, safe transition;
  • Beginning the process of meeting those needs by setting up services, ordering the necessary equipment and developing a plan for follow-up with the patient’s physician.

When all goes according to plan, the patient progresses toward recovery goals and receives ample support outside the hospital. Under ideal circumstances, patients comply with discharge plans and discharge to an environment that does not undermine compliance and safety, but rather strengthens these important factors.

How Often Does the Plan Actually Work?
Despite the Herculean efforts of well-trained hospital professionals, patient behavior in the outside world is a bit of a wild card. Add age and medical instability to the mix, and the odds of success are hampered still more. Patients leave the hospital and leave the control of those who have been caring for them.

While most manage to stay out of the hospital, 20% will have an adverse event within three weeks of discharge and re-admit to the hospital within that critical 30-day window. ACA architects assert that 75% of these events are preventable, though the medical community has suggested that this number is inflated.

There are myriad unforeseen problems that can unravel the best-laid plans, but these events seem to occur most frequently:

  • Adverse drug effects (the most common post-discharge complication)
  • Hospital-acquired infections
  • Procedural complications
  • Poor communication between inpatient and outpatient service providers
  • Inaccurate assessment of the patient’s ability to care for themselves
  • Failure to enlist appropriate resources
  • Family inability to assume post-discharge care burden
  • Patients are discharged with test results pending and must return for additional treatment

Studies have shown that our current push for rapid discharge may, in fact, be part of the problem. It has been demonstrated that one extra day in the hospital cuts the risk of death in pneumonia patients by 22%, and that heart failure patients are 7% less likely to readmit if they, too, receive one extra day in the hospital.

In our modern health care era, it’s also true that patients may go home early against medical advice. When seniors on fixed incomes are informed that they are in the hospital under observation (a Part B Medicare stay), they can opt to go home rather than incur charges they will have to pay privately. Observation patients will not qualify for post-acute coverage in a rehab environment, and discharge home without the benefit of these strengthening measures unless they are willing to privately fund them.

The hospital locus of control is rather limited. Hospitals can and have focused on improvements in medication reconciliation, infection control, communications between hospital units and between service providers, and prevention of premature discharges.

But there are a host of issues at home that patients may or may not report that will damage their chances for success outside the hospital. Seniors are somewhat prone to overestimating their abilities, and they will work hard to protect the status quo – fearful of change and a loss of control over their circumstances, seniors will often conceal their struggles rather than seek help.

The Hidden Perils
As community-based care managers, we have the unique opportunity to see the home environment and the manner in which the patient functions within it. Although they may not recognize these challenges as significant, and may neglect to tell hospital care providers about things at home that cause them to neglect their own needs, patients will return to houses and apartments that feature the following precarious conditions:

Environmental Issues
No matter how comfortable the client may feel in the familiar environment of home, it may well be that the home’s design presents risks to them in their retirement years that were minor nuisances in their youth:

  • Stairs from the living area to the bathroom that have inspired some of our clients to stop drinking fluids during the day to avoid another trip up/down the stairs;
  • Laundry at the bottom of the steep, poorly-lit basement stairs;
  • A detached garage that requires a treacherous walk to the car during winter weather;
  • Garbage cans on the back alley, involving the same icy/snowy walk with a bag full of trash.

Some environmental challenges are created by the patient or a family member over the course of time. An estimated 15 million people in the U.S. have a clinically significant problem with hoarding. The patient will not report this issue to hospital personnel because they don’t perceive it as a problem, and they wish to avoid the humiliating glare of outside attention. Hoarding lays the groundwork for a variety of health- and safety-related trials:

  • Narrow passageways that are difficult to navigate;
  • Floors covered with paper, creating an uneven surface;
  • An inability to perform activities of daily living, such as bathing, food preparation, toileting;
  • Squalid, dirty conditions that are particularly hazardous when surgical wounds are present or immune systems are compromised;
  • Isolation – hoarders rarely allow others inside their homes and go to great lengths to hide the problem. They may refuse home health and/or caregiver visits for this reason.

An eyes-and-ears assessment of the home can identify many of these issues and head off the potential disasters that result from them.

Cognitive Issues
Mild to moderate cognitive impairment can go undetected during the course of a short hospital stay. Patients living alone, in particular, may be showing signs of escalating cognitive deficits and there is no one in the home environment to note these changes. Because social skills tend to remain relatively sharp even as other skills decline, patients may fool the rotating shifts of care providers in the hospital about their actual abilities to comprehend and retain new information.

The cognitively-challenged patient could return to the hospital due to the following telltale problems:

  • Medication mishaps (missed doses, switched medications);
  • Malnourishment, dehydration and/or illness due to spoiled food;
  • Lack of follow-up with physicians;
  • Rehabilitative failures.

When we think of elder abuse and exploitation, we tend to think of strangers at the door offering household repairs, or a scammer from overseas approaching people on the internet. While these things certainly occur, they do not comprise a significant percentage of elder abuse scenarios. The National Adult Protective Services Association reports that 99% of abusers are family members or trusted others. Sadly, only one in 44 cases of financial abuse is ever reported.

Exploitation impacts care and recovery in the community in subtle ways. The family members who agree to hire a caregiver or offer other support during the critical 30-day post-discharge window may, in fact, have absolutely no intention of doing these things. Caregivers cost money, and exploiters may have a vested interest in preserving assets for their own use. That frail patient may well go home alone. That unstable patient’s bank account may already have been drained by an abusive adult child, leaving them without assets to pay for care.

It is not uncommon for those making care decisions to also be the beneficiaries of a loved one’s estate. There is an inherent conflict of interest when the adult children must facilitate services that drain funds from an estate they hope to inherit; while many want what is best for their parents, regardless of cost, others weigh the need for care against their own looming financial problems or need for financial support.

Neglectful agents under the powers of attorney have been reported to senior services. If the patient is competent, they can name a new agent (though many are afraid to upset the acting agent); if they are not competent, it may be necessary to pursue guardianship to protect the client from further abuse.

The Patient is a Caregiver
That charming 85-year-old man preparing to discharge home may cheerfully report that he lives with both his wife and adult son. It sounds like an ideal, supportive arrangement. The truth, however, is that the man takes care of his wife, who suffers from dementia or some other debilitating disease, and/or his adult son who remains home because he is developmentally disabled. This stalwart patient is likely to disregard care plans and discharge orders since doing so would interfere with his care of others…and wind up right back in the hospital.

Today’s seniors grew up in an era where family took care of family. A long-ago promise to a spouse that “we will always take care of each other” may result in a stoic struggle at home to provide care that might best be provided elsewhere or by a professional caregiver.

A child with developmental or psychiatric challenges, per this same tradition, is embraced by the family and kept at home. It’s a perfect plan….until mom and dad begin to age and find even caring for themselves difficult. They often push on, enmeshed in the caregiver role as they are, and discharge from the hospital to diligently offer care to others and not attend to themselves at all.

We see and address these situations with great frequency. Elderly parents need help formulating a plan for their spouses and dependent adult children when they can no longer offer direct care themselves. The options include:

  • A careful assessment that identifies the pertinent needs of all involved and illuminates options that may serve to keep the family together while receiving professional care and oversight;
  • Naming a successor or co-guardian for an adult child;
  • Identifying placement options for disabled children, and facilitating a gradual transition to a setting where life skills can be sharpened and peer relationships developed;
  • Supporting an elderly parent as they separate from “failure to launch” adult children who demand that their parents pay their bills, provide them with a home and meet all their needs, despite being fully capable of doing for themselves. If the parent wants to move to a facility, for example, they are likely to meet substantial resistance from an adult child who relies on them for money, housing and other necessities.

Underlying Psychiatric or Addiction Issues
Discharge failures can be connected to habits and addictions that will not be reported by the patient as they leave the hospital. They may “self-medicate” with alcohol on a daily basis, or even overuse prescribed medication for pain. Depression and isolation are especially commonplace among the frail elderly, and these particular forms of anguish can be mitigated, at least temporarily, with alcohol and drugs.

Some of our psychiatrically impaired clients, though perhaps delusional and actively engaged with voices only they can hear, can successfully weather a short medical hospital stay without exhibiting for medical professionals any indicators of their interior lives. If not for our involvement, the psychiatric component of their history might never be reported or known, in spite of the degree to which it can impact a successful discharge.

We have worked with a number of individuals over the years who initially presented as alcoholic and/or drug-addicted. We discovered that these problems evolved as a result of undiagnosed psychiatric issues that alcohol and drugs could momentarily muffle. Beneath every substance abuse problem may lurk another problem the substance was adopted to manage.

The co-mingling of prescribed medication with alcohol and/or other prescribed (and unreported) medications can result in disaster. Patients who re-admit with fall-related injuries or issues stemming from medication “mishaps” could be using unreported drugs in addition to those with which they were sent home.

Geographic Isolation
Geographic separation in families has become quite common in the past decade or two. Where three generations of a family used to live within a few blocks of one another in the past, they now live several states away owing to job relocations and other factors.

It may be that the lovely, supportive adult children gathered around the hospital bed are each going to board a plane and go home as soon as the immediate crisis passes. They may try to manage their parents’ care from afar, and have to take their parents’ word for it that “nothing happened” at the follow-up physician appointment.

Family estrangements are another reality that will typically not be reported to medical professionals. Patients may be reluctant to mention that family bridges have been thoroughly burned, perhaps as a result of their own behavior. We had a client who talked about her son as if she had seen him the day before when, in fact, he lived overseas and they had not spoken to one another in five years.

An elderly patient who is geographically separated from those who might provide assistance and support is clearly more likely to struggle and fail at home. Neighbors can be relied upon for simple things, but as a person’s needs escalate, these casual acquaintances are going to become overwhelmed and less willing to carry the load.

Eyes and Ears in the Outside World
There is perhaps no greater purpose for a community-based care manager than being the eyes and ears for those who cannot physically be present in a patient’s environment. Often, we are the on-site manager for the geographically distant family and, just as easily, can be the eyes and ears of the medical professionals who serve a patient in a hospital or other facility.

The home environment yields a thousand indicators of its occupants’ success in managing ADLs independently. We will find the jumble of poorly-marked medications, the spoiled food in the refrigerator, the squalid conditions, the collection of 25 cats whose owner prioritizes their care far above her own.

The home environment may tell the tale of why a particular patient re-admits to the hospital time and time again. In cases where a patient’s ability to care for themselves is hampered by decisional incapacity, we can initiate guardianship proceedings, as appropriate, to ensure their safety and welfare going forward.

It is the business of a care manager to identify and solve problems for those who can no longer manage life independently. The hidden perils of discharge represent an array of problems community-based care managers routinely solve, directly contributing to the shared cause of readmission prevention.

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