Patient #1 is an elderly man was admitted to the local community hospital for CVA complications and after 6 days, was transferred to the regional tertiary hospital about 40 miles away for hip surgery required after he fell out of the bed and was found on the floor. There, he has been on a battery of specialties as it is a teaching hospital. After an additional 2 weeks there, the case manager tells his wife that he needs transferred to a rehab hospital, but he cannot tolerate the minimum hours for therapy, so he will have to go to a skilled nursing home first. He has used 20 Medicare days. He does not have a coinsurance. The wife cannot seem to make any decisions, but a son/daughter who lives out of state has been given medical power of attorney. What are options or concerns if the case manager and physicians are just addressing the spouse and not the decision maker? Communication with the case manager is confusing to the mother, who then cannot really describe what is going on when speaking to son/daughter. The case manager seems to want someone to decide quickly versus giving more options. How could one plan a more patient-centric discharge planning focus?

Patient #2 is an elderly woman who has a family member appointed with medical power of attorney (MPOA). The patient has 3 chronic illnesses: diabetes, CHF, and lung disease. She was admitted into a community hospital where she was on a ventilator in the ICU and utilized her full days and is in day 8 of her co-days. The case manager advises discharge to a long-term care hospital that can wean patients on ventilators, but the pulmonologist has not been involved in the care planning and is generally difficult to contact for an order to d/c to the regional LTACH (which can handle vent weaning). The LTACH can discharge the patient home with home health or to a SNF if additional therapy is needed. There is also an attending physician (internal medicine) who defers to the pulmonologist. The patient has Medicare Part A and B and no secondary insurance. Her resources are limited. The case manager has discussed benefits this person has under Medicare and the financial impact to the patient and the hospital if a decision is not made. The case manager doesn't really provide any recommendations as he/she states "we are not allowed to recommend any post-acute care facility under HIPAA. The case manager will not make a referral and the MPOA is not familiar with area resources. The case manager says "Well, you have to figure this out for yourself." The MPOA then questions this statement as HIPAA does provide for post-acute facilities to evaluate patients prior to discharge as they are 'involved in continuation of care' and can review records. The MPOA asks why those agencies cannot come and evaluate the patient for admission. If she continues to stay in the hospital, she is incurring expenses. Describe an effective patient handoff procedure/policy to have a seamless continuum.

Describe how one would handle each of the scenarios. Compare and contrast similarities and differences in planning an effective patient hand off/discharge.