Bridging the Gap

March 14, 2019

By Karen Wilkinson, RN, NHA, CLNC – CareerSmart® Learning Contributor


What do a 62-year-old stroke victim and a 93-year-old with dementia have in common?  It seems like they have quite unique needs until you place them at the point of care transition.  The common bond then becomes their coincidental struggle to understand and cope with the issues of care management through the spectrum of care.  Unfortunately for patients and their family members, navigating the system at the dizzying rate of speed in which decisions are made can feel like an overwhelming task at a point of great vulnerability.  Hospital discharge planners, social workers, and insurance case managers play pivotal roles in coordinating patients’ needs and communicating care options available. Regardless of our job title, we all need to be more proactive in our efforts to assist those patients and families we come in contact with.  Stepping into the shoes of our patients and their families and viewing our “system” through their experience is a good place to start.  So, let’s take a look at these two patients and the challenges they have faced in their journeys. 

The 62-year-old stroke victim was working as a CFO one month ago, when he collapsed at work.  Through what the family views as a miracle, a physician and a nurse were nearby, recognized his symptoms and called 911 immediately.  He was quickly transported to a nearby trauma center that excels in stroke treatment and was afforded the latest in treatment options, which saved his life and resulted in medical stability.  His life, however, was catastrophically changed as he was left with hemiplegia, a tracheostomy, ventilator support, and a feeding tube.  While in the neuro-ICU, his wife made agonizing decisions about resuscitation, treatment, and surgeries.  When his medical condition began to stabilize, she was given a list of long-term acute care (LTAC) facilities and asked to “go look at them” and choose one.  As healthcare professionals, we understand the situation and think nothing of this request.  We know the medical needs of this patient can be met at the LTAC level, at least as far as his insurance will cover.  To a non-medical person, this request seems preposterous and impossible.  Why does he have to be transferred to a different facility? What is an LTAC?  What am I looking for?  What makes one facility better than the other?  How long will he be there?  Who pays for this?  With help from “medical” friends, a facility decision was made and communicated to the case manager.  No one, however, explained that the transfer would occur the next day.  Now at the LTAC, weaned from the ventilator and finishing antibiotics for a respiratory infection, a list of subacute facilities has been presented along with the explanation that insurance will likely cover the LTAC for one more week.  There has been little time to think beyond the present situation in the last month or to consider the long-term ramifications and needs of both the patient and his family.

The 93-year-old patient with dementia was recently hospitalized after being found on the floor at her assisted living facility.  After the expected exams, scans and tests found nothing of significance to explain the fall, she was discharged to a rehabilitation facility within her continuing care retirement community.  The family has been informed by the facility discharge planner that insurance coverage will end in two days and she cannot return to her assisted living unit because of safety considerations due to underlying dementia.  Accommodation in the memory care unit within the same complex is not currently available, so the conundrum faced by the family is where she should go in two days.  Unfortunately, in this case, the discharge planner was of very little help.  A list of memory care units in the area has been provided to the family and they are left alone to identify a new facility that will accept the patient.

Healthcare professionals, whatever their roles, cannot solve all that is challenging within our healthcare system.  But, we can do better.  How?  First, understand the pace at which we operate in healthcare is normal to us but leaves patients and families reeling.  We need to find new ways to communicate which validate and support patients and their families at these critical times.  For example, are we only available in person?  Is there an alternate, timely way for a family member to communicate with us rather than leaving a voicemail if we are not available?  Second, it can be quite challenging to understand the medical complexity of the patient while receiving information from multiple physicians, therapists, nurses, and other healthcare professionals.  How can we best help coordinate interactions between providers and patients and their families?  Or, how can we best summarize the findings of providers and the ramifications for the family?  Lastly, choosing from a list of unknown providers for the next level of care is overwhelming.  How can we better explain the care needs of the patient and guide families in this task so informed decisions can be made?  For example, has information about  the Centers for Medicare & Medicaid Services “compare” websites been provided so facility/agency  inspections and ratings can be accessed to help enlighten?  We must think beyond our job responsibilities to see the whole picture as it impacts patients and their families.  As they are able to navigate more effectively and efficiently between levels of care, outcomes will improve for everyone.

You may also be interested in:


Centers for Medicare & Medicaid. (2019).  Medicare.gov. Retrieved March 14, 2019 form https://www.medicare.gov/medicare-search?global_search=home%20health%20compare

March 27, 2019

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