“Medical treatment is not enough; we must also consider how to relieve a patient’s psychosocial situation to improve and sustain their health,” writes Roberts.
As an aspiring physician, my summer working as a social service intern at CAMC Memorial Hospital in Charleston, West Virginia, will forever impact my views of health care and how I will practice medicine. In particular, this experience taught me much about the role of the physician beyond diagnosing illness and providing immediate medical solutions. Rather, I learned that physicians and other hospital workers can play an essential role in assessing patients’ health status holistically in terms of all of the socioeconomic factors that contribute to their medical conditions.
My role within the social services and case management department of the hospital involved working closely with the social workers, nurses, and physicians to develop discharge plans for patients. In communicating with members of the hospital staff as well as with patients and their families, I was able to determine what medical needs patients would require when they left the hospital. After identifying these needs, I then worked with providers to initiate services for patients. I helped patients obtain health insurance and other assistance to pay for expensive medications, set up their home health for care outside of the hospital, found beds in nursing facilities, or arranged for services such as the delivery of home oxygen tanks and other medical equipment. In addition, I assisted patients in finding transportation to their doctors’ appointments and checked in with family members to make sure that patients received proper care after returning home. These efforts to ensure care outside of the hospital sought to minimize readmission to the hospital and provide opportunities to maintain good health.
Discharge planning allows the hospital staff to prepare for patients’ discharge so that they can have the shortest possible hospital stay while also receiving appropriate medical care. While the primary purpose of the hospital is to treat ill patients, it also faces the financial pressure of not receiving compensation for extended care or for treating unnecessarily readmitted patients. Though the doctors and nurses do not want to discharge patients before they are medically ready, they face the problem of meeting the hospital stay lengths allowed by insurance companies. For each diagnosis or reason for hospitalization, insurance determines the appropriate number of days that a patient should be in the hospital. Insurance provides payments for those days, but if the length of stay exceeds the allowed number of days, the hospital must cover most of the extra cost. For Medicaid and Medicare, the allowed days for a hospital stay is usually determined by a single diagnosis, even if a patient has several diagnoses. Thus, the hospital staff faces the challenge of trying to treat patients within the allowed number of days while not discharging them before they are ready, especially since insurance payments to the hospital are reduced for readmissions within thirty days. By never discharging patients before it is medically appropriate and ensuring that patients receive the proper care and resources when they leave the hospital, the hospital reduces costs associated with readmission. These efforts are especially important given that the Hospital Readmission Reduction Program (HRRP) established by the Affordable Care Act (ACA) requires Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare, no matter the cause or medical reasons for these readmissions.
I worked with social services and case management to ensure that patients had the necessary resources available when the physician deemed them ready for discharge. We needed to assess what factors indicate a risk for being readmitted due to chronic health conditions, individual behavioral patterns, or other socioeconomic factors. I completed risk assessments by conducting psychosocial evaluations. During these evaluations, I talked with patients and learned more about their home environments, support systems, and access to health care resources. I asked them about who they lived with, if they had a primary care physician, if they required any special medical devices at home, and if they had problems with accessing medications or other treatments. Further, I utilized medical records and information provided by the physicians, nurses, and patients’ families to determine what patients needed following their discharge. From this work, I learned that successful discharges were just as important as care in the hospital. Even if patients had the entirety of their symptoms treated while in the hospital, they were likely to return if they did not have the proper support systems in place when they left.
Most patients showed low risk for readmission. However, patients with significant financial and other barriers to accessing medications and extended care faced greater challenges after discharge. I learned to identify the signs and indicators that led to readmission. I often recognized names in the patient registry of persons who were frequently readmitted to the hospital and was able to recall the risk factors that contributed to this pattern. Individuals of lower socioeconomic status often carried a significant risk for readmission because they could not afford medications and treatments. Patients who could not afford the prescribed treatments often skipped taking their medications. These individuals were also unlikely to be involved with a primary care physician, causing them to receive medical care only after health problems worsened. Others lacked transportation, leading them to miss doctors’ appointments or not pick up their medications on time. Others who lived alone or had little social support were unable to call upon others when they needed assistance and were much more likely to be readmitted to the hospital. Sometimes mental illness or drug and alcohol abuse compounded the health problems due to a lack of access to proper nutrition.
These patients’ health problems were not the result of mere medical explanations but rather due to a combination of socioeconomic factors.
One case in particular stood out in relation to socioeconomic determinants of health. I worked with a homeless man who had been repeatedly readmitted to the hospital due to disruptions of his IV antibiotic treatment for an infection. The man had been readmitted to the hospital because the shelter where he stayed did not have the proper electrical connections required for his IV treatment. As a result, he kept starting and stopping his treatment until eventually he was unable to continue. When he came to the hospital for a second time, he was started again on the antibiotic regimen, but the doctors sent him home before the treatment was completed since hospitalization was not required. He went to live with a reluctant relative who did not allow the home health nurses to enter the house, preventing the man from having his medications refilled. Consequently, he was unable to complete his treatment regimen outside of the hospital. When he returned, the physicians who treated him thought he was just incompliant with the treatment, but conversations about his living situation revealed that non-compliance resulted primarily from factors beyond his control. After understanding his homelessness, the physicians decided to keep him in the hospital for the remainder of his treatment in order to ensure its completion. This case demonstrated the importance of physicians taking time to understand their patients’ health in relation to socioeconomic determinants and not merely in light of their current health and medical history. Furthermore, this case illustrates that physicians have a responsibility to understand whether or not a patient has the resources or capability to comply with the prescribed treatment. When it is not clear that the patient can access or maintain a treatment plan, the physician, which one day may be me, must determine whether there are other treatment alternatives available and with other members of the hospital staff to determine if a patient can receive assistance for treatment.
This kind of assistance is not sustainable in large numbers due to the strain that it places on hospital resources. I learned much about the financial burden placed on hospitals due to uncompensated care, and in particular I saw that hospital resources are limited when serving in highly impoverished areas such as Charleston and environs. Many patients at the hospital were reluctant to leave at discharge, with many hesitating to leave for arrangements made for them at shelters or even nursing facilities. For these patients, the hospital provided stability, good care, and proper nutrition that they were not otherwise able to access. As a result, many hospital readmissions reflected the absence of these determinants in peoples’ lives. However, the role of the hospital is not to serve as a long-term home or permanent source of resources. Extended and repeated hospital stays are not the long-term solution for impoverished individuals’ health problems. Thus, the social services department must address health issues that go beyond patients’ immediate health crisis in order to ensure proper resources and opportunities for good health when they leave the hospital.
The solutions provided by the social services department such as tickets for transportation and referrals to shelters did not provide long-term relief for some individuals. They also need to get to their future appointments, resolve long-term homelessness, and maintain treatment regimens. I often found that while I was able to assist the social services department in providing immediate help; we played a limited role in preventing future poor health and readmission. However, our ability to connect patients with programs for assistance served as the best opportunity to impact their long-term health. Although the role of the hospital is to provide medical care, hospital workers and physicians can play a key role in connecting vulnerable patients with programs for stable social and economic support. Hospitals can improve the health of their communities by partnering with associations that work closely with issues such as housing, food, transportation, and other needs. In making such connections that offer a smoother transition at discharge ensuring that socioeconomic determinants of health are met, hospitals can improve the long-term health of discharged patients and reduce rates of readmission.
My work during this internship taught me much about health as a holistic outcome resulting from both social and medical factors. While poor health can be caused by limited access to resources, compromised health also compounds the conditions of poverty. In speaking directly with sick patients and their family members, I learned about the burden poor health places on individuals and their families. Families struggle financially as they work to balance work and payments for medical expenses and necessities. Much of what I learned was through personal interactions with patients as I encountered their life stories and what led to their current health status. Many patients found comfort in knowing that someone listened to them and cared about providing support. I discovered that much about a patient’s life goes unnoticed by physicians as they go from one patient to the next treating only immediate medical needs. In many instances, physicians ignore aspects of patients’ lives that explain their health situation and could impact their compliance with treatment. As a result, in my future career as a physician I hope to connect with my patients and provide comprehensive assessments by understanding their health beyond their medical history and immediate biological state. Medical treatment is not enough; we must also consider how to relieve a patient’s psychosocial situation to improve and sustain their health. As such, healthcare professionals working with impoverished communities must be equipped to assess the reasons for their patients’ health needs and know what extra-medical resources are available to support good health.