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Determining when and how to discharge adult patients can present some difficult dilemmas. 

When I was a medical student (not that long ago,) my instructors emphasized a clear message over and over: decisions about patient care should never be tainted with consideration of cost.

When I entered residency, however, things were a little different. I found myself pursuing a career in a field of medicine in which practically no patient or family member wants to remain in the hospital. Kids want to be home. Their families want to bring them home. If a test or procedure or treatment could be done at a later time, they were all for it. A discharge in pediatrics is an event everyone involved looks forward to and celebrates.

This is not as often the case in adult medicine, wherein patients commonly have no circle of caregivers waiting to bring them home. Patients who can’t care for themselves are considered an inconvenience, a problem, or a burden. Going home for an adult patient doesn’t always mean that he or she returns to a place that’s comfortable and safe to recuperate from an injury or illness. A discharge for an adult patient, especially someone who is elderly or has significant co-morbidities, is an event often fretted over and dreaded.

I know this and keep it in mind when speaking about utilization with my practicing colleagues. They are on the front lines, sitting at the bedsides of their worried patients or across the room from their patients’ family members. But, I also know that there are other challenges that cannot be ignored because they are difficult to address.

If your physicians persistently balk at discharging patients because they fear they won’t do well at home, look into your case management and nursing workflows for assessing patient needs. Are they starting the day the patient enters the hospital? Or does this topic come up once the physician determines the patient is ready for discharge? Do your doctors know who to go to for discussion about their patients’ home needs and concerns about eventual discharge? What if the patient alludes to being unable to return to the hospital for a procedure or test? What does the physician do then? If they have no other known alternatives, keeping the patient hospitalized without medical necessity will be the result every time.

Physicians want to do what’s best for their patients. Many times, however, what’s best for the patient is not what the patient wants. I have yet to meet a young child who’s in agreement with receiving an immunization. Yet receive scheduled shots they will. This is a much simpler situation than a patient who can no longer care for themselves at home, but doesn’t want to enter into a skilled nursing facility. This is a situation no one wants to find themselves in, including physicians. The risk of empathy trumping medical necessity is high.

Physician advisors need to re-emphasize the perils of keeping patients in the hospital when it’s not medically necessary. Nosocomial infections, medication errors, falls – these are all real risks to the patient and should not be overlooked. Conversation with the patient on this topic should be as routine as explaining why antibiotics aren’t appropriate treatment for a viral infection.

But for many physicians, it’s not. Doctors don’t want to be the bad guy. They don’t want to be seen as uncaring, or kicking a patient out of the hospital. Emphasis on patient satisfaction scores has created even more complications. Physician advisors should strive to serve as a compassionate sounding board and encourage their doctors, pointing out that they are doing the right thing.

While unpleasant, informing the patient of an appropriate plan of care – even if the patient does not want to hear it – is still a part of their responsibility as clinicians.
And it’s our role in case management and utilization to help them do it.


Juliet B. Ugarte Hopkins, MD, CHCQM

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and contributes to ICD10monitor.

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