What happens when a patient is medically ready to leave a hospital, but is not mentally capable of making decisions?
Ideally, they have designated a proxy or guardian to help guide the way. But if they haven’t, finding a legal guardian can take weeks or months, while the patient is taking up bed space needed by others.
Dartmouth-Hitchcock Medical Center is trying to streamline that process.
Jasper Chen is a resident psychiatrist at Dartmouth-Hitchcock, and also part of an allied residency program to improve health care delivery.
When he got to Dartmouth, he noticed that a handful of patients were lingering in the hospital long after their medical procedures were finished.
Some have brain injuries, or Alzheimer’s, or dementia. Others have psychiatric conditions that make living alone unsafe—but lack family members able to care for them after they leave the hospital.
“They have actually completed their acute medical care and they are waiting for the next disposition to happen, waiting for the court to appoint a guardian so they can move onto the rehabilitation facility or the skilled nursing facility,” Chen explained.
But that legal red tape can take time to cut. So Chen and others are trying to speed up the guardian search—and free up beds.
“So that another patient can come who needs the bed much more than the person who was previously there. And they may need the procedures. For example, they may need a cath to save their life, they may need life saving surgery because they were in a trauma and they need to come to the closest trauma center, which would be DHMC. And you know our hospital has been on diversion in the past and patients have to be choppered or driven by ambulance to Boston for example, when we have a full house. So that happens, and we are trying to prevent that situation from happening,” Chen said.
In fact, Dartmouth Hitchcock was on diversion—which means there were no beds available and incoming patients would have had to be diverted to a different hospital—on a day Chen recently held a meeting with a nurses and social workers to brainstorm ways to help patients leave the hospital after their medical procedures are finished.
At the meeting, the hospital’s risk manager, Jim Gregoire, reported that New Hampshire probate judges are starting to streamline the guardianship process.
“They allow us to have either telephone testimony or live video testimony so we don’t have to have the doctors often traveling an hour each way to court,” Gregoire said.
The interdisciplinary team is also creating checklists and better electronic records about guardianship for patients.
They say it’s a challenge, though, to care for patients from two states with different mental health systems.
The need is greatest where a patient has no family to provide care after a hospital stay is over. There are procedures where a guardian can be appointed who has no relationship to the patient. Vermont has a state-run guardian agency, and New Hampshire has two non-profit guardian agencies.
The costs of these independent guardians are covered by the patient, often through Medicare or Medicaid. Social worker Yoni Stevens says all three can be swamped with requests.
“I’m trying to work with them on a patient now but they really don’t want him because they are so overwhelmed,” Stevens lamented.
But Fletcher Allen hospital, in Burlington, says finding guardians has not been a major problem. And the president of Vermont’s chapter of the National Alliance on Mental Illness sees a different, bigger obstacle.
Wendy Beinner says even when patients do get guardians, there are not always enough mental health beds to send them to after they leave the hospital.
“And from my experience,” Beinner said, “that’s been more of the sticking point.”
Still, over the past year and a half Dartmouth officials say streamlining guardianship has saved more than 200 hospital days that would otherwise have been needlessly spent by patients ready to move to a recovery or long term care facility.
Dr. Chen said it’s hard to measure how much money the hospital has saved by filling vacated beds with patients needing procedures that generate revenue. But the goal, he said, is to improve care for everyone.
He added that the process would be even smoother if more people designated health care decision makers for themselves long before they got sick.