SOCW 6204 Week 11 Complex Discharge Case Study Example

Six Transitions and Four Decisions: A Complex Discharge Case Study Following a Patient From the Emergency Department Through Rehabilitation, Home, Readmission and Home Again, Setting Out at Each Decision What Was Known, What Was Decided, What Happened and What Social Work Would Do Differently

Student Name

Walden University

SOCW 6204: Medical Social Work I

Instructor Name

Month Day, Year

Six Transitions and Four Decisions: A Complex Discharge Case Study Following a Patient From the Emergency Department Through Rehabilitation, Home, Readmission and Home Again, Setting Out at Each Decision What Was Known, What Was Decided, What Happened and What Social Work Would Do Differently

Timeline

Table 1

Transitions in Mrs. Augustin's Care

Days are counted from the first emergency department visit. The case is a composite built for teaching.

Case Presentation

Mrs. Rosette Augustin is a 79-year-old Haitian-born former home health aide who speaks Haitian Creole and some English. She has heart failure and lives on her own above a flight of stairs. The psychosocial assessment found strong motivation to return home, a fear of nursing facilities rooted in her own work, possible early memory changes reported by her daughter, and supports including a cousin in the building and a church community. Her daughter, the caregiver assessment showed, could manage medications, transport and some bathing but could not provide overnight care.

Decision Point 1: First Discharge

Known: she could not manage stairs, she had fallen at night alone, her daughter could not cover nights, and her heart failure limited endurance. Decided: short-term skilled nursing rehabilitation near her daughter, with home as the stated goal, rather than home with home health or intensive inpatient rehabilitation. Buntin et al. (2010) reported fewer deaths but more permanent placements after skilled nursing stays for hip fracture, so the plan named home as the goal from the first day to guard against the second outcome. Happened: she completed three weeks of rehabilitation and returned home on day 27. Hindsight: the decision held up. Social work would do one thing differently: begin the application for overnight home care hours during this first admission, since the need was already clear.

Decision Point 2: The Goals Conversation

Known: her heart failure had progressed during the admission. Decided: an advance care planning conversation, with an interpreter and both children, in which she named her daughter as proxy, stated her priorities and left resuscitation open pending a talk with her cardiologist. Happened: her priorities guided later decisions, and the family referred to them during the readmission. Hindsight: the conversation was well timed. Social work would follow up on the open resuscitation question sooner; it remained open at readmission.

Decision Point 3: Discharge Home From Rehabilitation

Known: her diuretic dose had changed; she speaks Haitian Creole; her daughter would be at work at the time of discharge. Decided: discharge at the end of the day, with teaching by a nurse in English when the interpreter line had a long wait. Happened: she continued the old dose and was readmitted with fluid overload five days later. The interpreter review by Karliner et al. (2007) favors trained interpreters over improvised ones, and Coleman et al. (2006) found that a transitions intervention that coached patients through medication changes and follow-up reduced rehospitalization. Neither form of support was in place at this transition. Hindsight: social work at the rehabilitation facility should have scheduled the discharge teaching in the morning with an interpreter and the daughter on the phone, and should have arranged a pharmacist or home health nurse visit within 48 hours to confirm the new dose. The hospital social worker could also have sent a handoff note to the facility flagging her language needs for discharge.

Decision Point 4: Final Discharge

Known: the readmission had a fixable cause; her daughter's strain was rising; overnight care was the main gap. Decided: overnight personal care hours through her state home care program, supported by an advocacy letter; a palliative care referral; interpreter-supported medication teaching with teach-back, her daughter present; and a family meeting. Happened: she went home on day 38 with each of these in place. Hindsight: this discharge did what earlier ones did not, but it took a readmission to get there.

What the Case Teaches

The case shows how a series of reasonable decisions can still fail at a single transition. The level-of-care decision and the goals conversation were sound. The failure came at a routine moment, end-of-day discharge teaching, where language access, timing and the daughter's work schedule met. Social work's contribution across the case was to keep the patient's goals in view and to see the family's limits clearly. Its main lesson for practice is to treat every transition as a point of risk, especially for patients who depend on interpreters and on family members with limited availability, and to arrange teaching, follow-up and handoff notes before the transition rather than after a failure.

References

Buntin, M. B., Colla, C. H., Deb, P., Sood, N., & Escarce, J. J. (2010). Medicare spending and outcomes after postacute care for stroke and hip fracture. Medical Care, 48(9), 776-784. https://doi.org/10.1097/MLR.0b013e3181e359df

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42(2), 727-754. https://doi.org/10.1111/j.1475-6773.2006.00629.x