By Adrienne Trzonkowski, MSM RRT-ACCS, RRT-NPS, AE-C, CCM
As I begin to type my daily end-of-day projected discharge email, something hits me. I am writing the name of a gentleman who has been with us for over a hundred days. He is not going to rehab, he is not going home, he is not going to a skilled nursing facility (SNF), he is going to hospice.
I have sat in the same office behind my fellow Case Manager, Ashley, for weeks listening to her heartfelt, gut-wrenching, and honest conversations with this patient’s sister. “No ma’am, there have been no changes. No, he does not respond. No, the trach will not be able to be removed.” These phone calls have been long and sometimes repetitive. Week after week, Ashley has made the same call and is met with the same questions. Every week, this patient’s sister is looking to hear a little bit of hope that her brother is showing signs of improvement.
Conversations like these can take a toll on your psyche, but they have to happen.
Behind every discharge is a story. If we go back to grade school, we learned that there are five parts to every story, starting with an introduction and ending with a resolution. As case managers, we have a hand in all elements of the patient’s story. The ending, or in our case, the discharge, can be the part that challenges us the most.
Rarely is a patient’s stay free of barriers when it comes to discharge. Barriers we are used to, such as restraints, pending procedures, late medical equipment deliveries, SNF bed availability, and transportation, are some of the easier challenges we face daily. But the most significant barriers are those that wake us up at night, make us go home and squeeze our loved ones tight, and sometimes bring tears to our eyes.
As case managers, we learn so much about our patients and families during their stay. We grow to see them beyond the patient and more of the person they were and aim to be after their stay. We connect with their families and feel, hear, and see the sadness in their voices and eyes when their loved one does not improve.
The relationships we build during a patient’s admission can make discharges even harder when the outcome is not what the patient or family expected.
We all probably have a story or two. The family that does not want their loved one to leave because they are scared the care will not be the same at the accepting SNF. The patient who does not want to go to rehab and thinks they can manage themself at home. The spouse who wants “one more week” with us to see if there is a chance their husband/wife will come off the ventilator. And all too often, the family who really needs help understands that their family member is transitioning, and hospice is in the best interest of the patient.
So, what keeps me coming back every day? What is my “why”? I know I am not just speaking on behalf of myself when I say, with every sad or trying discharge, there are at least three success stories. On top of the successes, there are the miracles. I have had the honor of seeing so many people come in on a ventilator and with a PEG and leave for rehab on a nasal cannula and a regular diet.
I love to organize what we call a “clap out”. Our hallway is lined with staff as the patient rolls by on their stretcher, headed to rehab. The patient’s smiles and the staff’s tears of joy are a reminder of what we do. These stories make me realize I am right where I belong. My team has learned to celebrate the successes and to close the door if needed, to decompress about our defeats.
I am fairly new to case management and have a whole new appreciation for my new career and my colleagues. We are more than discharge planners, we are advocates, confidants, educators, cheerleaders and sometimes, a shoulder to cry on. We help write our patients’ stories, and although most have happy endings, some do not.
The next time you are preparing to hit send on that end-of-day discharge email, take a moment to reflect. Celebrate the patient who was admitted on the ventilator and is now leaving for acute rehab on room air. For patients whose outcome isn’t what everyone hoped for, brainstorm ways to prepare for the next time your team is met with such challenging conversations. Taking a moment to talk with your team about the journey to the discharge may be educational and even therapeutic.
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Bio: Adrienne Trzonkowski is the Director of Case Management at an LTACH. Her background is in Respiratory Therapy where she has worked in adult and pediatric critical care for 18 years. She transitioned to LTACH as a Case Manager in 2023.