Acute Care Case Managers are Charged with Providing and Orchestrating a Safe and Timely Discharge Plan
by Florence Simmons

Hospital case managers are charged with developing and orchestrating safe and timely discharge plans. Barriers to discharge may include lack of adequate funding and responsible family, and the patient’s condition at the time of discharge.

My caseload included an elderly female from China who was hit by a car while visiting her daughter in the United States. Her injuries included a significant closed head injury that rendered her essentially comatose. She had a tracheostomy placed for airway maintenance and a feeding tube for nutritional supplements, and was totally dependent in ADLs.

The patient lacked medical insurance, including travel accident insurance. She was not eligible for any type of funding resources to assist with post-discharge placement. According to the daughter, who was her only relative in the United States, the patient was not eligible for insurance reimbursement from the driver of the car because she was at fault in the accident. The daughter noted that she had young children to care for and could not take her mother home to care for even though she was a non-practicing pediatrician. She lacked finances to support her mother even after attempts to raise monies via her church.

This was a nightmare case! This lady survived the trauma, but was in a totally dependent state possibly for her entire life, lacked finances and family support, and was a placement disaster. What was the best discharge plan for her? The best option was to transport her back to China with her family and access to some type of funding. Transportation was the first concern. An air ambulance would cost over $50,000 and the family could not pay this. There were no charitable international flights. I contacted the Chinese embassy and they were willing to extend her visa indefinitely, but offered no other type of support. Members of the Chinese society could not raise the money. No nursing home was willing to accept her.

Planning started with multiple meetings with the daughter, letting her know that she would have to raise at least a portion of the air transportation back to China. I met with hospital administration and convinced them that it would be more cost-effective to pay for her transport to China instead of keeping her in the hospital for an indefinite period. Someone suggested that we negotiate with a broker to find transportation. The final transportation was air ambulance from South Carolina to Pennsylvania with a nurse accompanying the patient and daughter, and then a commercial flight from Pennsylvania to China with the daughter taking responsibility for her care.

The broker arranged for us to pay for nine seats on a commercial flight at a reduced rate. The area was turned into a sick bay that contained a stretcher with mattress overlay, oxygen, suction and supplies to meet her needs during the transport. The daughter was taught how to care for her mother using a care plan that included suctioning, trach care, tube feeding, turning, etc. She had a prior knowledge of most of the care as a former physician. The transport took place as planned and the patient arrived safely in China.