The pager goes off for the umpteenth time today, somebody just shouted my name at the nurses’ station, and I’m struggling to remember how and why I ended up here. I arrived here in Charleston, West Virginia from my small, sleepy college town of Berea, Kentucky, and I was immediately immersed into the fast-paced environment of this urban hospital, Charleston Area Medical Center’s Memorial Hospital. In addition to the adjustment to the new environment, I arrived with a very naïve outlook on the healthcare system and its ability to help people. Exactly what is “health”? And what could I, a 20 year old college student, do about the health of West Virginians? Ultimately, I would find out that a large part of healthcare is completely out of the control of the hospital staff, but that there is still tremendous value in what we are able to do.
My specific role in the social services department involved “discharge planning,” which means that I initiated and carried out services to assist patients after their discharge from the hospital. Each day, I met with patients to conduct psychosocial assessments and to help determine their post-charge needs. I was also responsible for setting up these services, such as home oxygen or home health, after they were ordered by a doctor. A large part of my day often involved talking to patients and asking them thoughtful questions. It’s strange how much people will tell you, if you truly listen to them. I heard about their medical problems, their demons and addictions, their estranged or abusive family members, and always, always about their financial problems. And after a few weeks, it was easy to see that these external factors had a much greater impact on my patients’ health than their pneumonia, congestive heart failure or other medical conditions. We did our best to ensure that our patients made a smooth and successful transition from hospital care to post-discharge health care, but many of the influencing factors were out of our control.
Through our services, we strove to reduce readmission, which is typically defined as a hospital admission within 30 days of a previous hospitalization. Within a few weeks, I learned to spot a potential readmit from a mile away. More often than not, their readmission involved their socioeconomic status. Those of higher socioeconomic status had money to pay for home health care, expensive equipment, pricy medications, and a competent and involved primary care physician. They left the hospital well taken care of, and with low risk of a readmit. Those of low socioeconomic status often lived alone and lacked medical and psychological support. Unfortunately, they also seemed more likely to suffer from mental illnesses and drug or alcohol abuse, compounding their medical problems. Without money to pay for medications, many of their readmissions were closely linked to not taking their essential prescriptions. They also lacked good primary care, which often landed them back in the emergency room for the second (or third, or fourth…) time.
Just identifying these basic psychosocial issues was not enough. We had to do our best to ameliorate these problems, socioeconomic problems that were deeper and complicated than we could ever imagine. For example, many of our patients did not have transportation, making follow-up doctors’ appointments difficult or impossible. Some patients walked inordinate distances to their appointments, others just skipped them. Other patients lacked a stable and safe housing situation, with many coming to the hospital off the street or from prison. From the hospital’s standpoint, these patients needed to leave the hospital when they were well, but the patients often balked, reluctant to return to an unhealthy and unsafe living situation. While we did our best to solve these immediate issues by providing taxi tickets or referrals to a homeless shelter, our solutions were unable to address the long standing needs. One taxi ticket might get patients to their next medical appointment, but it won’t allow them to attend their appointments for the next six months. A bed at a homeless center will give them short-term shelter, but their medications may be stolen, landing them right back in the hospital. Often, our so-called solutions allowed the patients to go home, but they felt like putting a Band-Aid on a knife wound. It’s emotionally exhausting to try so hard every single day to help patients when you know that so much of their health is inextricably tied to their socioeconomic status, which is sadly out of our control. When working with impoverished patients, it was not uncommon to have situations where there really is no solution. To be honest, it can be quite difficult to maintain a compassionate and positive outlook when it’s so easy to fault the patients for failing to arrange a ride, being unable to pay for medications, or lacking a safe place to stay. It’s easier still to become discouraged and calloused over our own inability to help. But at the end of the day, we must remind ourselves that we did our best to help in each situation, and that some circumstances are just out of our control. So I focused on the small victories—the times when we were able to help, in however small a way. I helped people get their insurance to pay for expensive medications; I set up home health care for people who needed extra care; I arranged for oxygen tanks to be delivered to people’s homes. I helped people find rides to doctors’ appointments; I called family members to notify them of a loved one’s hospitalization; I gave out meal vouchers for the hospital cafeteria. And perhaps most importantly, I listened to people and comforted them when they were broken and diseased in a hospital bed, letting them know that their health mattered to me, and because of that, their housing, transportation and financial situations also mattered to me.
But although I was concerned about my patients’ living situations and health behaviors, most of their post-discharge lives were out of my control. I saw tremendous disconnect between my patients’ hospitalized lives, where they were well-fed and well cared for, and their post-discharge life, where they lacked many key determinants of health. To better connect these two disparate situations, it would be beneficial to have more communication and cooperation between the hospital and various agencies that address these issues. Although it would be most efficient to have the health care providers themselves involved in these issues, I don’t feel that it is currently feasible. We could try to address these needs ourselves, but we aren’t trained or equipped to do so, and we honestly are not staffed well enough to do so. Rather, if the hospital invested itself in trying to partner with area organizations, it would benefit both our patients and the hospital. If we can focus on what we do best (health care), and effectively connect our patients with organizations that specialize in housing, transportation, and food, we will increase our patients’ post-discharge success.
The major takeaway from my internship was that health is a multifaceted state. It involves so much more than just someone’s medical condition. That medical condition is tremendously influenced by socioeconomic status, which in turn impacts the patient’s housing situation, transportation resources, family situation, and ability to pay for medications, all of which are in jeopardy when someone is in poverty. I want to remember that while my patient’s medical problem may be a straightforward, relatively easy fix, their psychosocial situation may not be. The patient’s socioeconomic situation must also be recognized and assessed, because it has tremendous effects on the patient’s medical condition. Rather than looking at just one aspect of a patient, I want to remain committed to a comprehensive assessment, and to providing care and support for all aspects of a patient’s life. In order to truly improve patients’ health, hospitals and clinics must be better equipped to address holistically their patients’ health, rather than simply providing medical help.
I snap out of my idealistic daydream as the pagers, phones, and voices continue to swirl around me and I realize that while there is pain, sorrow and death here in the chaos of the hospital, there’s also tremendous joy, relief and life. While much of our work may seem futile, I’d much rather be here, making however small a difference, than outside just talking about theoretically changing the health care system.
Kaitlyn Reasoner, Berea College ‘16, November 2014