Interview Story - Solved a Problem

While working as a social work case manager at the Rusk Institute of Rehabilitation Medicine at NYU Medical Center in NYC, there was a situation where I was assigned to provide a safe and timely discharge from the hospital for a patient who had become paralyzed on one side of the body from a stroke. I learned that she lived in a 7th-floor walk-up building in Queens. She would not be able to return to her home due to accessibility issues and high danger risk in the event of a building or apartment fire.

I saw this as a situation to support the patient and family’s involvement and sense of self-determination as well as minimize unnecessary costs for the hospital from what it appeared would be a complex, time-consuming discharge process.

My first step was to act immediately by meeting the patient to observe her mental, health, and disability status in person, and then went about gathering her health history and current health status from the medical chart, her physicians, nursing, and other professional staff. Because the patient was not able to speak well, it was necessary to contact the family (the patient’s daughter) to obtain a complete psycho-social history of the patient including her living situation, how long she lived there, what the home meant to her, the layout of the building, her financial situation, her social support structure, etc.

Secondly, I reviewed and analyzed all of the information from these sources in order to make a professional assessment which included a list of issues that would need to be addressed and resolved in order to assure the patient’s safe discharge to the community.

Third, I sat down with the patient’s daughter to review my assessment of the problems which would need to be resolved prior to discharge and the many options available to them in terms of community resources and services. I included them in the planning and respected her wishes that the patient not be placed in a nursing home.

Together, we developed a plan which would include changing her mother’s residence and moving her to a ground floor apartment near her own home where the patient could maintain some sense of independence, have her belongings around her. We communicated closely several times per week so that I could support the daughter, monitor her progress, answer questions and help keep the process moving forward without unnecessary delays.

This was the most difficult community discharge experience of my career due to the complexity of the patient’s daughter having to search for another apartment that was accessible, then physically move the patient’s belongings from one residence to another, obtain legal permissions, apply for federal and local financial resources, and arrange for home health services. I felt that I was able to develop a very effective working relationship with the daughter by supporting her in her decisions of what she wanted for her mother and that she was very satisfied with the outcome. Also, I believe that because of this mutual cooperation and diligence, we were able to reduce the number of days the patient remained in the hospital beyond Medicare reimbursement days, minimizing extra costs to the hospital.