PSA Review of Discharge Planning Issues - 12/7/07

OCFS did not specifically survey districts regarding concerns surrounding discharge planning issues in the health care realm. Instead, numerous discussions were held over the course of the past year during regional PSA meetings and individual county visits resulting in extensive input.

1) Hospitals

Although there continues to be occasional examples of inappropriate discharges or role confusions (such as guardianship questions), generally there many fewer concerns expressed regarding hospitals than had been the case even a year ago. In part that may be because of the educational emphasis on this topic- the NYPWA repeat presentation of the Difficult to Serve Client from our first conference and the dissemination of information regarding that best practices example through out the state. PSA supervisors have been actively encouraged to meet with hospital discharge planners using the model hospital agreement to clarify roles and procedures. Following a recent Steuben Co. incident where a homeless woman with Stage 4 breast cancer was discharged to the DSS office in a cab on a Friday afternoon, meetings have addressed procedures and protocols with positive results.

In contrast, Sullivan Co. reports continued incidents of patients with no prior PSA involvement being discharged directly to the DSS lobby.

And in NYC, the issues are:

  1. discharging without notice to APS when APS is known to be involved.
  2. while non-APS hospital patients can be discharged with CHHA service, and then converted to home attendant service through HRA (called expedited hospital discharge), the home care program in NYC doesn't do that for APS clients. However, HRA is in the process of developing a pilot to permit it for patients previously known to APS.

2) Nursing Homes

The only concerns noted have been some isolated incidents of difficulties dealing with AMA referrals. Although the referrals to PSA were considered appropriate, PSA has been running into situations were the facilities have refused to provide departing patients with medications or scripts, placing clients at greater risk until these issues can be resolved in the community. A DOH opinion on that practice would be appreciated.

3) Adult Homes

No issues noted. We did have an excellent example of PSA/DOH/Adult Home collaboration in Syracuse where joint efforts prevented an adult home eviction of a severely demented gentleman who was being financially exploited by his wife.

4) Home Care

PSA clients tend to be the difficult to serve. They may have co-occurring disorders, tend to be resistive, can be socially isolated and often reside in home environments that are often far less than ideal. They generally do not fit the criteria of an optimal home care patient. Regardless, it is the charge of PSA to utilize least restrictive alternatives and maintain these clients safely in the community.

Beyond the issue of aide shortages in various areas of the state, the health and safety requirements regarding both admissions and discharges from home care services has been the most problematic area across the board for districts in almost all areas of the state. Some find that agencies require that the patient meet all the requirements of 10 NYCRR 763.5 (b) rather than just one (be self directing AND have informal supports AND be able to be left at home). PSA also finds in many cases that agencies are unwilling to consider PSA as a community support in determining safety issues.

The interpretation of safety hazards to staff has been very restrictive in some cases. An example from the Hudson Valley region was the refusal of an agency to accept a referral for an elderly gentleman coming out of the hospital because there was a gun in the house. The gentleman, who lived in a rural area and had been a hunter most of his life, had a rifle. There had never been any threats or inappropriate use. Neither were there any mental health issues. However, his referral was dismissed without even the opportunity to discuss alternatives for gun storage. Thresholds for such discharge criteria as verbal abuse can also be quite variable across agencies and regions.

NYC PSA has a problem with cases where the agency withdraws from long term cases with very short notice to PSA (a few days or sometimes even the same day that a PSA referral is made). Typically HRA has been successful in convincing the agency to stay on until they get a difficult to serve home care vendor in place and the CHHA continues to provide the minimally required nursing service with the HRA HA in place. This raises the question as to what the minimal levels of care are that are supposed to be provided upon discharge until another plan is established.

HRA just proposed, in a meeting the Commissioner had with VNS, that VNS CHHA must refer to APS 60 days before withdrawing. VNS is currently reviewing HRA's proposal.

OCFS plans to replicate meetings with DOH regional office, home care providers and PSA supervisors similar to the very helpful one held in Syracuse over the last year. This meeting served to clarify a number of these issues from a DOH and provider standpoint and created future avenues for information and case discussion down the road.