A recent article by Robert Kane published in the January 19, 2011, issue of the Journal of the American Medical Association (JAMA), “Finding the Right Level of Posthospital Care,” is a must-read for anyone interested in discharge planning issues. Bob packs a lot of information into this article--a literature review of physicians’ roles in discharge planning, a list of what should be considered in a discharge plan involving long term care, and what a family should know about finding an appropriate discharge planner. However, I think he missed an important opportunity—pointing out the need for other trained professionals to be involved in the discharge process. Having started my career in social work as a hospital discharge planner, I feel very strongly that discharge planning belongs in the realm of social work.
I applaud Bob’s suggestion that physicians should play a crucial role in transitions from the hospital to long term care services. However, it should not fall to them to work out every detail. Instead, social workers can and should be the facilitator and advocate for the patient, allowing the physician to focus on medical necessities. It is inefficient for physicians to cross-train in areas of social work expertise, such as the ins and outs of long term care services, financial issues, the patient’s and families’ wishes and ability to pay, etc.
Perhaps the role of discharge planning has changed. Bob states that it seems that hospital discharge planners are concerned only with quick and efficient discharges to save the hospital money. If this is true, it needs to change. I believe that physicians should partner with social workers to encourage them to do the job they are trained to do--advocate for the patient; work with the family; keep abreast of the patient’s medical treatment and progress by speaking with the physicians, nurses, and other medical personnel; and keep informed about community services and eligibility requirements as well as all long term care options. Talking to other social workers and working with social work leaders to develop geriatric social work competencies, we all agree that appropriate and adequate discharge planning is critical for care transitions and preventing or reducing hospital readmissions. Social workers, who are trained in care coordination, are the right health care professionals to bring all the necessary staff and resources together to create discharge plans that will benefit older persons.
In this article, Bob also alludes to the fragmentation of social services and care/case managers. There isn’t even a common name to call the profession. He mentions several sources a family can contact in order to ascertain whether or not a care manager is available to assist them. This is a problem with social work; it is fragmented, lacking a common title or a clearinghouse for families to go to obtain needed information. We need to improve this.
So while I want to thank Bob for writing this article and pointing out the importance of discharge planning, I politely disagree that “physicians have a crucial role to advocate for, and facilitate, better decision making.” I believe that physicians’ crucial role is to work with social workers who will advocate for and facilitate better decision making for the older patient. I implore my fellow social workers to advocate for their crucial role as discharge planners and key health care professionals in care transitions.