Additional Barriers to Discharge Planning
Barriers for inpatient psychiatric hospitalization placement are discussed in our chapter on care options and treatment teams under “barriers for placement” in the “template for ED psychiatry pre-rounding” section. The treatment team should be aware of any of the potential barriers to discharge the patient either home, to a hospital alternative program, or to a hospital setting, and be prepared to address these barriers.
Some of the more common barriers when trying to discharge a patient out of the ED and back into the community may include housing issues, especially if the patient is homeless, or if the patient is unable to return to the home they are in because a family member or concerned roommate is not willing to accept them back into the home. In these cases, the hospital social services team may need to get involved in order to help solidify a housing plan for the patient.
Even though this is a small part of the discharge planning process, it can create a barrier and add time to the patient’s ED stay. We recommend that a discussion on transportation needs and availabilities be completed as early as possible. Some hospital systems may be willing to help finance transportation resources for patients discharging from the ED, although the willingness to do this may vary.
Any way you look at the transportation issue, it is almost always less expensive to provide the cost of transportation of the patient to a safe predetermined location, out of the ED, than it is to have the patient wait in the ED for a transportation solution that may not materialize for many hours.
Regardless of which hospital one looks at, several hours in an ED is almost always more costly financially, and also increases potential liability, than the cost of a public transportation voucher, or even a taxi ride. While we don’t advocate for free transportation for everyone and understand the financial barriers, we do highly recommend that hospital systems look at this issue and have a reasonable plan in place to address it. In addition to the cost angle, operationally having one less patient that does not need to be in the ED is always optimal in regard to the flow of the patients and creating capacity in the ED.
We recommend encouraging MD-to-MD dialogue regarding any outstanding medical concerns that may be holding up the patient’s transfer from the ED to the accepting facility, whether the facility is a crisis respite housing program or an inpatient psychiatric hospital.
More often than not, we see these hold ups arise around chronic medical issues that reveal lab results that are abnormal, but are the “baseline” results for the patient in question. The function of an MD-to-MD warm handoff or discussion is to reassure the accepting MD and treatment team that the abnormal lab values or findings do not represent an acute, concerning presentation.