The Discharge Process Begins on the Day of Admission: A Lesson on Reducing Readmissions

Way back in 1975, when dinosaurs still roamed the earth, I learned some very valuable lessons regarding hospital readmissions that were to last me my entire career. I even got a surprise bonus for learning these lessons.

I was a hotshot third-year medical student, and I knew absolutely everything! On the surgical service, our chief resident, Dr. Singh, had assigned me a patient to care for, and I charged head on to the task. Mr. Plummer was a homeless alcoholic who had a propensity for being beat up on the streets resulting in frequent hospital admissions. Each morning I dutifully came in at 5 am to tend to his wounds carefully. He had deep decubitus ulcers that required daily debriding, and after weeks of diligent care, we started to see nice, healthy, pink tissue filling in the ulcers.

On rounds one morning, Dr. Singh was duly impressed by Mr. Plummer’s progress and stated that it was time for him to be discharged, and I was told to arrange for this. Despite knowing everything, I had no idea how to accomplish this. He had been discharged many times before and kept coming back. His wounds and injuries which were thought to be healed recurred, and he always returned to his life on the streets. What to do, what to do?

“The lessons that I learned then are still valid today. The discharge process truly begins on admission and consists of educating the patient, engaging and activating them, and making achievable follow up plans.”

Sensing my dismay, Dr. Singh said words that I remember to this day, “You might consider asking for a social work consult.” I really didn’t know what a hospital social worker did, but a quote from the 1973 Woody Allen movie Sleeper immediately came to mind, “Are there strange futuristic creatures out there that I don’t know about? Like something with the body of a crab and the head of a social worker?” But I digress.

Since I idolized Dr. Singh, and knew that he never could be wrong, I immediately took his advice and requested a social work consult. That afternoon, I was paged to the floor and told that the social worker was there. Walking onto the ward I expected to see a crab but instead I saw this absolutely gorgeous young woman who introduced herself as Mary from the social work department. The first question she asked me was when he would be ready for discharge and, barely able to get a coherent sentence together, I mumbled “today?” The hotshot medical student had met his match in the guise of Mary, the social worker.  

It was then that I learned my most important lesson regarding reducing readmission rates. Mary looked at me with her stunning blue eyes and said, “Don’t you know that discharge planning begins on the day of admission?” Mr. Plummer has been in the hospital for two weeks, and I wanted him to be discharged today. Clearly, I had missed the boat by two weeks.

Social Worker Mary met with Mr. Plummer and tried to get an understanding of what went wrong with the previous admissions, which led to his readmissions and assembled quite a list of social issues that must be dealt with. Mr. Plummer was on disability with a meager income and was a chronic alcoholic. He had some cognitive dysfunction, was never able to live on his own, and had a knack for getting himself into risky situations. He had no clothes and no belongings, nor did he have transportation. She went down the list and educated, engaged, and motivated Mr. Plummer in becoming responsible for his own care. With his assistance, Mary found an incredible placement for him, outside of the city in a pastoral country environment. True, it was a state hospital, but it totally met his needs. She recruited my roommates and me to collect clothing for him and even procured a boom box for him. Mr. Plummer was truly excited and enthusiastic about going to his new home.

At a follow-up visit a week later (he had never before come for a follow up), he insisted on seeing Mary and even gave her flowers, which he had dug up from the front of the hospital. Medically, his wounds were healed; he was happy and adhering to the discharge plans.

The lessons that I learned then are still valid today. The discharge process truly begins on admission and consists of educating the patient, engaging and activating them, and making achievable follow up plans. Today, technology can play a big part in this. Our health care providers are busier than ever before, and platforms like the GoMo Health Concierge Care program can help to determine the patient’s needs, help to educate them and motivate them. After discharge, it can keep them motivated and be able to identify problems early through continuous communication.

I mentioned that I received a surprise bonus for learning about reducing readmissions back in 1975. 

That bonus was Mary, the social worker, who has been my wife for more than 40 years.