Hip Replacement Discharge Planning: A Case Manager's Guide

Assessment of the Situation

As a case manager for the patient in this scenario, there are at least four easily identifiable healthcare issues associated with the patient's discharge:

1. Patient safety related to the second-floor placement of the apartment and navigation of two flights of stairs with a walker while using pain medication and recovering from hip replacement surgery.

2. Patient safety with regard to the size and condition of the apartment, which has limited room for navigating with a walker, as well as cluttered space and rug placement — all of which are barriers to proper walker use and ambulation, an essential aspect of recovery.

3. The potential for patient non-compliance with the new medication regimen for diabetes and the dietary plan for weight and glucose control.

4. Patient well-being with regard to isolation and the inability to follow normal routines, such as helping in the bakery (two flights down), eating in the bakery, and interacting with others during recovery (Byers-Lang & McCall, 1993).

These issues are crucial when planning a patient discharge, especially given the nature of the individual's injury, which was likely brought on by poor health and by the patient navigating two — possibly three — flights of stairs to take out trash from the apartment. The injury itself, the extended recovery time required, and the need for physical therapy and ambulation make the apartment a poor choice for recovery.

Additionally, there are inherent concerns regarding the potential for limited social interaction due to apartment isolation and family caregiver constraints. Some of these issues could be mitigated with in-home care from a visiting nurse and a nursing aide; however, safely transferring the patient to and from the ground floor on a daily basis to eliminate social isolation would not be feasible for a nursing aide. The patient's size, the layout and dimensions of the apartment stairways, and the patient's compromised health and ambulatory ability would all exclude this option from the care plan on safety grounds. Therefore, many factors associated with positive recovery outcomes would be lacking, and a discharge to home would not be recommended until after a period of rehabilitation that would allow the patient to safely and independently navigate the stairway.

Interdisciplinary Team Composition and Roles

A five-member interdisciplinary team to help determine the appropriate discharge placement for this patient would include the case manager, a hospital social worker, a hospital rehabilitation specialist, the patient's discharge nurse, and his primary care physician.

The case manager (discharge specialist) would produce the assessment documentation, gather as much information as possible, and disseminate it to other team members. This would include a site visit to the home if the description of the home is believed to be insufficient, and the case manager would make recommendations for effective interventions if home discharge becomes the only option. The case manager would also be responsible for communication among team members and for scheduling meetings — both for the team and for the patient and family — to explain the discharge plan and evaluate further needs for communication and action.

The hospital social worker would receive all pertinent information, including the assessment from the case manager, site visit results, insurance coverage information (including plan coverage for alternative placement and/or home health care), and the family's commitment to providing care under the various alternatives offered. The social worker would then research options for the patient, including cost and availability of beds in a local rehabilitation center or long-term care center. The social worker would also conduct follow-up at one week, two weeks, four weeks, and six weeks post-discharge to make further recommendations where changes in patient needs are identified.

The rehabilitation specialist would receive the same assessment and site visit results and would meet with the patient to evaluate his post-surgical ambulatory ability, range of motion, ability to self-manage braces and surgical wound care, and overall capacity for self-care — both immediately and over a six-week period following surgical intervention (the recommended duration for intensive rehabilitation care). The specialist would then develop an additional assessment of the patient's perceived ability to care for himself in a home setting or in a recommended alternative setting.

The discharge nurse would be responsible, in collaboration with other team members, for providing a brief assessment with recommendations, as well as an evaluation of any patient or family factors that could affect the discharge plan. The discharge nurse would offer a final recommendation based on patient interaction and a limited review of assessment materials. The discharge nurse — together with the case manager and social worker if needed — would also explain the discharge plan recommendations and alternatives to the patient and family, and would provide post-discharge safety literature (Merten et al., 2011).

The patient's primary care provider would be asked to review health data and assessment information, and to apply his or her long-term knowledge of the patient and family to formulate a discharge recommendation. Given that the patient had not sought medical care for ten years prior to the injury, this knowledge base may be limited. The primary care provider would also follow up with the patient after discharge.

References

Borg, C., Hallberg, I., & Blomqvist, K. (2006). Life satisfaction among older people (65+) with reduced self-care capacity: The relationship to social, health and financial aspects. Journal of Clinical Nursing, 15(5), 607–618.

Byers-Lang, R. E., & McCall, R. A. (1993). Peer support groups: Rehabilitation in action. RE:View, 25(1), 32–36.

French, D. D., Bass, E., Bradham, D. D., Campbell, R. R., & Rubenstein, L. Z. (2008). Rehospitalization after hip fracture: Predictors and prognosis from a national veterans study. Journal of the American Geriatrics Society, 56(4), 705–710. doi:10.1111/j.1532-5415.2007.01479.x

Lin, P., Hung, S., Liao, M., Sheen, S., & Jong, S. (2006). Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. The Journal of Nursing Research: JNR, 14(4), 251–260.

Merten, H., Lubberding, S., van Wagtendonk, I., Johannesma, P., & Wagner, C. (2011). Patient safety in elderly hip fracture patients: Design of a randomised controlled trial. BMC Health Services Research, 11, 59.