You Can Go Home Again (from the Hospital), but There’s a Lot You Need to Know First

Dear Readers,

Thomas Wolfe may not have been thinking about hospital discharge when he wrote “you can’t go home again,” but he could have been. The process of going home from the hospital — and staying home — is so fraught with potential slips and mishaps that there is now a specific metric in hospital quality of care for the “30-day readmission rate.” Usually, the lower it is the better.

This month’s newsletter will help you make sure the transition from hospital to home is a successful one for yourself or a loved one.  It’s such an important subject, and one where a well-informed family member can make a big difference, that I suggest you save this newsletter and look at it again when the time is ripe.

Essential Questions to Ask to Know if You’re Ready to Go Home

Hospitals seldom wait until patients are fully recovered to send them home. Patients are discharged when doctors determine that they can survive at home or in a nursing facility or, worse, when an insurance company says benefits have been exhausted. Care delivered by professionals gets transferred to amateurs – ideally to a loved one/caregiver, but sometimes only to the patient himself.

A caregiver cannot meet the expectations of transition if he or she doesn’t know in advance what is expected. Successful transition requires preparation.

Make sure you have a written list of discharge instructions, and that anyone caring for you at home understands them. Caregivers might be instructed to:

* Change bandages and clean wounds.

* Give medications.

* Help the patient get into and out of bed, walk and perform other physical exercises.

Before you leave the hospital, consider the physical demands that might present problems at home. If there are stairs or other physical obstacles, figure out how they can be negotiated before you get home.

The patient might be ready to be discharged, but if the expectations for after care are too high, he or she might not be ready to go home. If that’s the case, consider transitioning to a rehabilitation or convalescent facility. If a patient seems too ill to go home-she’s struggling with life-critical functions such as breathing, pain is uncontrolled, etc.-someone (the patient or her advocate) must insist that she not be discharged.

When you find out when you’re supposed to be discharged, ask the doctor: “Is this the day of discharge because in your best judgment, I’m ready to go home? Or is it that when the insurance benefits run out and it’s difficult to fight the insurance bureaucracy for an extension?”

If insurance coverage is an issue and the doctor otherwise would extend your hospital stay, make an appeal to the insurance company. Insurers will often agree to additional coverage if the doctor sends a strongly worded letter justifying the need. But that may not happen unless you or your advocate asks for it. The squeaking wheel gets the grease.

And before you leave the hospital, schedule the first follow-up appointment at the doctor’s office.

Make Sure You Get Results of Late Tests

Last month, my patient safety blog reported on a new study about hospital tests that occur on the day the patient is discharged.  A shockingly high percentage of such tests were shown never to have been reviewed, and they also were shown to have a high rate of abnormal results.

The test may have been not needed in the first place.  After all, if they’re sending you home before they know the test results, what’s the point?

A commentary that ran with the new study in the Archives of Internal Medicine noted, “Because patients are judged ready to go home on the day of discharge, most tests ordered that day are unlikely to change care and are probably not needed.”

If a test has been ordered for the day you’re scheduled to be discharged, demand:

-a clear and full accounting of the need for the procedure;

-to know when the results will be available;

-to know when the doctor will review them.

If a reasonable case is made for the test, request to have it done before the day of discharge. If you are unconvinced of the need for the test, get a second opinion. If you do undergo the test, keep track of when the results are due, and contact the doctor at that time to request and discuss the results.

Key Things to Watch Out for Once You’re Home 

If you have trouble following the discharge instructions once you get home from the hospital, contact your doctor. Call him or her immediately if you experience:

– new pain or new fever;

-difficulty breathing;

-inability to take or tolerate medicine;

-inability to eat or drink.

-new mobility problems.

To learn more about preventing hospital readmissions and suggestions for improving transitional care, read “Preventing Hospital Readmissions: A $35 Billion Opportunity,” a report prepared by NEHI (New England Healthcare Institute),  an independent nonprofit health policy institute dedicated to transforming health care for the benefit of patients and their families.

What if You Want Out Now, and Caregivers Disagree? 

You have the right to leave the hospital even against your doctor’s wishes. Often, this happens because a doctor wants to perform a procedure a patient doesn’t want to have, such as a cardiac catheterization. Doctors commonly advise patients to undergo the test –which may or may not be necessary or considered best practice –because they believe it is indicated, OR they are protecting themselves from claims of insufficient care OR because it generates additional fees. My patient safety blog has detailed instances of the latter two sad scenarios here and here.

Doctors often try to persuade patients to remain hospitalized by telling them that insurance won’t cover any of their costs if they leave when the doctor advises otherwise, which is referred to as “AMA”-against medical advice.

This is an urban legend. A myth. It’s just not so.

A recent study in the Journal of General Internal Medicine confirmed that insurance companies do not hold patients hostage to AMA, and a first-person story recently showed how even well-intentioned doctors have been led to believe patients will get stuck with the whole bill if they behave AMA.

“Ethically,” wrote Dr. John Schumann on, “the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘pre-existing conditions,’ a mere grain of plausibility made this idea seem vaguely credible.

“To my surprise, many fellow attending physicians told me they had been taught the very same thing.”

In a casual survey of his colleagues, Schumann  found that doctors almost unanimously believed that AMA discharges incurred financial penalties. Even the AMA form given to patients had language stating that by signing, patients acknowledged financial risk.

Then Schumann called some insurance companies. Their executives told him that the idea of a patient leaving AMA and having to foot their bill as a result is bunk; it’s a “medical urban legend.”

The researchers for the Journal of General Internal Medicine scientifically reviewed whether insurers denied payment for patients discharged AMA. They also assessed physician beliefs and counseling practices when patients leave AMA.

Of 46,319 patients hospitalized from 2001 to 2010, about 1 in 100 left AMA. Among insured patients, payment was refused for about 4 in 100. But the reasons insurance companies balked at paying those bills were due to clerical mistakes, such as incorrect names. No cases of payment refusal occurred because a patient left AMA.

Still, most of the resident physicians surveyed-nearly 7 in 10-and nearly half of attending physicians believed insurance denies payment when a patient leaves AMA.

Many of those doctors told patients they would be penalized by insurance companies, even though they aren’t. And the vast majority of those doctors said the most common reason for payment refusal was “so [patients] will reconsider staying in the hospital.”

But it’s wrong.  So this is one thing you don’t need to worry about if you want to go home and the caregiver says you should stay.


To your continued health!

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Patrick Malone
Patrick Malone & Associates