OpenPlacement Community > OpenPlacement Blog > 5 of the Biggest Discharge Dilemmas: Barriers to Effective Case Planning

5 of the Biggest Discharge Dilemmas: Barriers to Effective Case Planning Christy Rakoczy

July 11th, 2013

Deciding on the proper time to discharge a patient can be a difficult decision and is impacted by a variety of factors. Poor decisions about discharging a patient can result in risk to the patient’s health and later readmission for a recurrence or development of a secondary condition. Defining the obstacles to effective discharge practices can help providers to improve processes resulting in better patient care and fewer incidences of patient readmissions.

Top barriers to making good discharge decisions include:

System BarriersDischarge2Policies or Issues

One factor that negatively impacts effective patient discharging can be the system itself. Issues such as having too few beds impacts the ability to make decisions by placing necessary constraints on the length of stay of some patients. In order to admit other unhealthy new patients, decisions must be made on who must be discharged, which can result in release of a patient who may actually benefit from receiving further care in the inpatient setting.

Another system issue is lack of staff. If physicians are overworked, they are unable to communicate appropriately with nurses and other staff resulting in a disconnect in communication from physicians to patients. Patients may, then, be undereducated regarding their care plan, negatively impacting their ability to successfully and fully recover.

Patients as a Factor

Some healthcare practitioners have cited patient preference as a barrier to effective discharge. Most cited was the hesitance of older patients to leave the hospital, particularly when lacking a caregiver at home. In many situations, older patients without caregivers are resistant to going to assisted living facilities and therefore oppose discharge.

Additionally, some healthcare professionals state that some patients lack of ability to understand how to take their medications or follow through on other post-discharge instructions, despite repeatedly providing the information, is a problem that contributes to readmission.

Social Factors

Social factors can be highly important in determining the success of a patient’s recovery. Discharge planners must learn about the patients’ social construct in order to effectively plan discharge and post-hospital follow up care. Issues such as transportation, lack of family support, inadequate funding, and time lag between discharge and receiving financial assistance from social programs can result in a patient not recovering as he otherwise would.

Healthcare Professional Factor

Sometimes healthcare professionals themselves can stand in the way of effective discharge planning. Nurses want to be more involved in the physician’s care of a patient and the decision making process, and cite that often physicians will rotate off duty or to other hospitals leaving and become unavailable to contact making it difficult to determine the physician’s preferred post-discharge plan.

Other healthcare staff point out that many healthcare professionals are not investing the necessary time to determine the patient’s situation outside of the hospital in order to be able formulate a realistic plan of action for after the patient is released.

Availability of Resources to Patients

In some situations, resources outside of the hospital are difficult to access due to various factors including education about resources, transportation to resources, geographical proximity, and various other factors. Often, finances can limit the ability of hospitals to provide extensive post-discharge follow up, resulting in an unsuccessful recovery and often readmission.


  1. Tom Binder July 15, 2013

    Many of the issues mentioned are directly addressed by the RightTransitions hospital-to-home program developed by Right at Home-In Home Care & Assistance. This program demonstrated a 65% reduction in hospital readmissions during a field pilot study and has been adopted in two states as a key tool in improving the transition and recovery processes. It focuses on several of the problems mentioned above, including caregiving at home, taking prescribed medications, and critical transportation especially for follow-up physician appointments. The biggest problem is that most discharge planners and hospital social workers just don’t understand the value of the non-medical caregiving at home as a critical part of the recovery process.

  2. Patricia Player Maxwell September 10, 2013

    The need to discharge is determined by several factors. Need for beds and insurance .
    That is why discharges oftentimes take place in a hurry on a Friday.
    If only families and hospital personnel were more knowledgeable about the role of a Care/case Manager. How often have I had to stop my client being discharged. Yes decision for discharge is often made before the patient is even over the des ease. Case in point. An elderly client with dementia was admitted for a low sodium blood count. He was in bed for 5 days without any PT deemed improving a decision was made that he would be discharged. He had not been out of bed , had not walked and on top of everything the Doctors had given him Haldol and were discontinuing cold turkey. You bet I had the Drs keep my guy in. Making sure he could still walk and that any withdrawal symptoms were monitored .

  3. Mariam Zinn October 31, 2014

    Knowledge Gap for Professionals & Families About Long-Term Care Choices

    The book came out March 2011 and is one of many that he’s written over the years on the subject as well as a similarly-themed January 2011 article in the Journal of American Medical Association among his hundreds of writings.

    “The Good Caregiver” was inspired in part by a group Kane founded known as Professionals with Personal Experience in Chronic Care (PPECC). In turn, he formed PPECC from a previous book, titled “It Shouldn’t Be This Way: The Failure of Long-Term Care,” he co-wrote with his sister in 2005, both of whom cared for their elderly mother.

    The books deal with Kane’s and his family’s lack of preparedness in providing caregiving for their mother and placing her in long-term care. The books, especially the latter of the two, are meant to guide and instruct caregivers on every step of the caregiving and long-term care decision process.

    In “The Good Caregiver,” Kane advises caregiving lasts a long time, is expensive, isn’t for everyone, heavily involves families and requires realistic expectations on the part of a senior’s closest family members.

    In 2000, the National Center for Assisted Living and the National Investment Center for the Senior Housing and Care Industries (NIC) both called for professional trade associations such as the American Health Care Association (AHCA), Assisted Living Federation of America (ALFA) and the American Senior Housing Association (ASHA) to mount an awareness campaign to inform families about long-term care options after releasing a study that then found a knowledge gap among Baby Boomers considering placement of their elders.

    Such a campaign has yet to fully materialize, however.

    To begin to fill the void for families, in 2007 Kane worked with a group of long-term care experts to develop a computerized system in the state of Minnesota — considered a pioneering state in terms of policy and laws regulating the industry in the last two decades – to help assess what services were needed to respond to frail older persons’ needs, especially in the area of Activities of Daily Living (ADLs).

    The assessment contains the most important questions that families can ask providers to ensure they can serve their elderly relative and comply with the law. To create the assessment, Kane says he and the group asked 200 gerontologists to respond to scenarios created from the assessment elements to recommend the most appropriate long-term care placements for each generated case.

    The project was backed by a grant from the Aging and Disability Resource Center Real Choices Systems Choices grant from the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Services (HHS-CMS) and the Administration on Aging (AoA).

    Area Agencies on Aging, a family’s local social worker or a hired private social worker case manager as proper advocates for families. Families can also lean on such resources as the Aging and Disability Resource Center information system.

    In the absence of social workers and public awareness, when asked if a family’s doctor or medical specialist could direct families, Kane says a doctor may not serve as an advocate but must be consulted to place a senior patient in a nursing home but in the case of, for example, an assisted living facility or a continuing care retirement community (CCRC).

    “Someone needs to work with families,” he says. “What kinds of long-term care facilities are the best at achieving those goals? Doctors would not likely know about that.”

    Doctors should help facilitate this decision, primarily by recruiting other experts to assist the families in times of crisis, frustration and confusion. In choosing a long-term care facility for their loved one, families need to consider quality, accessibility, availability, location and amenities; and most doctors would not know about these criteria, he says.

    “When people come to me for advice about finding a nursing home, I ask them, ‘Why do you need a nursing home?’” he says. “’Do you need to put [a senior] in an institution? [Have you considered] home care, respite care, adult day care?’”

    As he argues in “The Good Caregiver,” in the case of a senior relative who is released from a hospital or medical center after surgery, families may mistake a hospital discharge planner for an advocate. Kane says that realistically the discharge planner cannot serve as a family advocate because his or her decision is based on an institutional requirement to remove a patient from a facility in less than 24 hours.

    Kane explains that the only part of senior housing and the continuum of care in general that is truly fully regulated is the nursing home. He describes the continuing care retirement communities and assisted living facilities as “wide open.” He says that, with an assisted living facility, there is no assessment, no medical assessment, no in-depth examination of a senior’s functionality and primarily a word-of-mouth style of referral for families. He says most people are not “well-informed” about this.

    Assisted living has developed into a highly variable form of care. “If you go to an assisted living facility, you don’t know what you are getting,” he says. “Amenities vary for people as well as admission, discharge and pricing criteria.”

    Still, an American Health Care Association (AHCA)’s National Center for Assisted Living (NCAL) annually publishes its Assisted Living State Regulatory Review. Its 2011 Regulatory Review, available on its website at, summarizes state rules on licensure, definition, disclosure, facility scope of care, third party scope of care, move-in/move-out requirements, resident assessment, medication management, physical plants, residents allowed per room, bathroom requirements, life safety, Alzheimer’s unit, staff training for Alzheimer’s care, staffing education/training, administrator education/training, continuing education requirements and Medicaid coverage. The Department of Health and Human Services’ “Assisted Living and Residential Care Policy Compendium,” the latest one being in 2007, also cites regulations on assisted living services providers.

    All 50 states and the District of Columbia regulate the industry. In 2010 and 2011, 18 states are updating their policies in the aforementioned areas, most especially in Alaska, Arizona, Florida, Georgia, Hawaii, Idaho, Iowa, Kentucky, Maine, New Jersey, New Mexico, Oregon, Pennsylvania, South Carolina, Texas, Utah and Washington State.

    In 2010, the Long-Term Care Community Coalition (LTCCC) published an Overview of State Survey and Enforcement Laws, Regulations and Policies for Assisted Living, finding that state departments of health or social services oversee assisted living facilities.

    With respect to assessments, NCAL’s provider-members have adopted what is known as a “person-centered” focus to evaluate each senior patient’s individual needs.

    Yet, Terri Corcoran, board secretary, public relations chair and staff publication co-editor of the Well SpouseTM Association, a nonprofit association of spousal caregivers based in Freehold, N.J., agrees that social workers and discharge planners, not doctors, can best assist with a family’s decision to place an aging relative in long-term care.

    “Get as many facts as you can,” Corcoran says to families with seniors in need of care. “Doctors cannot really assist, aside from presenting the facts of the illness and the basic needs the patient will have for continuing care.”

    Corcoran, a senior who for the past seven years has provided care at home for her physically and mentally disabled husband, says a family’s decision about long-term care depends on the level of ability to cope.

    “You can’t generalize,” she says, when asked theoretically about an overwhelmed elderly woman who would have to provide care for a senior-citizen husband with functional, health and behavioral problems. “Each situation is different. It depends on how much a caregiver can physically and mentally manage, and how much help they get, either from other family members or from paid home health aides.”

    Corcoran says some caregivers have careers and do not have the time and energy to provide the needed care, which isn’t her case.

    “Some people have careers and they are not wired that way [to provide care],”
    she says. “It’s a very difficult decision and you can never say never,” adding that long-term care may be an option after years of care giving at home.

    “Not only are [families] not well-informed but [doctors, long-term care facilities] are also not aware of internal conflicts [within a family],” he says. “You bring a lot of baggage to the table [when you decide to place a senior in a long-term care facility.]”

    Furthermore its very important to respect that a skilled nursing need is not always requiring SNF. There is a huge population that have intrem – Skilled Nursing Needs. Adult Family Homes are a great marriage of Home like atmosphere, monitoring and supervision as well as Home Health billed to Medicare Part B. There is Medication managments as well as delegate nursing tasks available at a fraction of the overall cost to SNF.


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