A four dimensional crossroads in the healing process

James Donnelly, DSW, LCSW

A great deal of emphasis has been given in recent years to the necessity of implementing effective and efficient discharge planning programs in hospitals and long term care facilities. Much of the initial thrust of this effort came from a need to maximize the proper utilization of a very expensive resource such as a hospital or residential facility.  It has also been recognized that discharge planning has important clinical implications and, to implement such a program, clinical disciplines must address discharge planning as an essential part of their treatment plan for each patient.

In the facility discharge planning process, the financial and clinical concerns of the facility meet and sometimes clash.  On any facility discharge planning committee, financial department personnel sit side by side with the social worker, UR nurse and other clinicians.

Society also, as evidenced by the dramatic increase in state and federal regulations regarding discharge planning, has a strong investment in this issue.  Medical costs are skyrocketing. Both industry and government are struggling to balance issues of access and to good medical care vis a vis society’s ability to foot the bill.

In an often contradictory manner, many of the state and federal regulations address the government’s concern that the interests and safety of the individual patient do not get sacrificed to financial expediency, while a the same time putting financial pressure on hospitals to reduce overstays.

At the center of these concerns, of course, are the individual patients and families; they are faced with the task of understanding and coping with the impact of illness and the experience of hospitalization upon them. They look to both society and the hospital for healing assistance.

Discharge planning is a major crossroads for the interests of society, the hospital, patients and families of patients.  There is no doubt that the location of this crossroads is the hospital, and social workers along with our professional colleagues deal every day with actual and potential collisions!

The hospital is seen by patients and families as a place for healing.  This has been its function in society and why the sociologists have classified it as an organization that is an instrument of the healing professions and one in which the focus of healing takes precedence.

Increasingly, however, it appears that the concerns of the larger society that are not necessarily focused on healing are impinging more upon the hospital organization and its priorities; much of the focus of this impingement has been in the arena utilization and discharge planning.

If discharge planning is to serve the healing mission of the hospital as well as the financial realities of society, it is imperative that we, as practitioners, gain a clear understanding of the forces at play and how the discharge planning and healing processes are in conflict or can serve each other.  Without such understanding we risk the integrity of our own professional purpose and, willy-nilly, place our patients and their families at grater risk.

The healing process, the hospital and discharge planning:

The healing process

To put our thinking in perspective, let’s look at the healing process from the point of view of the patient’s experience and the function of the hospital as related to that.

Illness and disability are imposed, unwanted and disruptive realities.  They assault us.  They demand to be incorporated into our lives regardless of whether we want to or not.  They are realities that no one wants to deal with.  Initially, many of us respond to such assaults with depression, anger, avoidance, denial and postponement.

In the hospital, a major focus of much of our effort to help patients is on the biological repair of the assault.  From the point of view of the patients and their families, however, the essential focus of healing must be on their ability to incorporate the realities of illness and disability, while at the same time, reestablishing and maintaining a sense of meaning and significance in their relationships.

Illness and disability assault us at our very core: they challenge our sense of being real, significant and of worth.

Response to this challenge is the patient’s and family’s primary role in their own healing process. To be effective, any assistance that we as social workers and medical staff offer, must be experienced by the patient as an essential part of this greater task.

Our patients and their families are not philosophers! They don’t often talk to us or themselves about how this illness has challenged meaning in their lives.  They don’t identify the task before them as reconstructing a new environment of meaning in which they can, once again, feel significant and real.  They just try to cope.

Their experience of meaning in their lives is contained less in ideas and more in the daily routines and patterns of their relationships: with themselves, each other and the community at large. They talk about how the illness and disability have disrupted and assaulted these relationships and are forcing them to change things they do not what to change; to make decisions they don’t want to make.

At the heart of all our relationships, with ourselves, our intimates and the community at large are the mutual expectations that we place upon ourselves and each other and the community.

Expectations are the currency of all our relationships. They define and contain our sense of meaning in these relationships.  The impact of illness and disability severely disrupt these expectations.  Patients and their families face the task of having to renegotiate all their relationships involving the patient, taking in to account these unwanted realities.

Dealing with this central task of renegotiating expectations is the primary role the patients have in their own healing. Our attempts at providing medical care must be integrated into the patient’s experience of this process of renegotiation of expectations if they are to be useful to the patients and, therefore, effective.

The hospital

Instinctively, as individuals and as a society, we recognize that once a person has experienced the assault of illness and disability, there is a legitimate need for a “time out place”, a place where a person can take refuge from the everyday expectations of one’s fellows and society in order to recover and attend to the task of healing.

Such a place, initially, is the hospital. The ancient sense of hospice is the essence of hospital.

Aside from being a place where medical professionals apply their knowledge and skills to the task of biological repair, the hospital is also a place of refuge in which patients have time and a facilitating environment to begin the task of re evaluating and renegotiating expectations.

This means that the hospital serving, in part, as a “time out place” is by its very nature a transitional environment that is designed to be at the service of the process of healing. This process has a beginning, middle and an end; and although the hospital plays a critical and essential role, it is by no means the place in which the entirety of this process takes place.

The process begins at the very moment when illness and trauma strike.  The process ends when patients and families have re integrated their lives taking into account the realities of illness and disability – without sacrificing the continuance of meaningful relationships with each other and the community at large. To the extent that this process is not complete, healing is limited or thwarted.

The function of the hospital in this process is to provide an environment where forces of healing can be identified and focused and where expectations can be suspended in order for them to begin to be re negotiated.

Discharge planning

Discharge planning, as we have pointed out, is the arena for many potentially conflicting interests.  In order for us, as professionals serving the healing process of our patients, to keep the conflicting interests from violating both our professional integrity and that of the hospital experience, we must keep constantly before us a clear understanding of how discharge planning is essentially linked to healing.

Discharge planning as part of the healing process is rooted in the reality that the hospital as refuge is and must be a transitional experience. Indeed, proper use of the hospital environment demands that its transitional nature be highlighted right from the beginning.

Effective and ethical discharge planning starts with the proper orientation and education of patients and families to the correct use of the hospital experience.  The essence of this orientation and education must be in helping them identify the basic task facing them and the critical nature of their own role in the healing process:

…that they begin renegotiating the expectations they have for each other and the community at large.

Without a clear orientation of the patient to their own essential role in the process of healing and the presentation of medical treatment as a part of this process, discharge planning can only be experienced by patient and families (and indeed, ourselves as well) as a premature and uncaring attempt to eject them from an environment of refuge and hospice which they properly feel they need and are entitled in order to heal.

Discharge planning is intrinsically and essentially linked to the proper orientation of patients and families to the use of the hospital and other community resources as part of the basic task facing them and their efforts at reconstructing a meaningful life space through renegotiating expectations.

The crossroads

Now that we have looked at the root of discharge planning in the healing process of the patient and family, let’s examine in more detail the four dimensions of patient, family, hospital and community and how they intersect in the discharge planning process.

First, let us visualize these dimensions for ease of analysis:

Patient

.        .       .

.           .          .

.              .            .

.                  .               .

.                      .                 .

v

Hospitalß….……………….><……………-> Community

.                        .                     .

.                     .                   .

.                  .                .

.                .             .

.            .           .

.        .      .

v

Family

We can look at this little diagram as a kind of chart or map of a whole system of mutually defined expectations that must be addressed by hospital and medical staff and patients and families as well as the community at large. The expectations we hold for each other do not exist in a vacuum. We can only understand and address one set of expectations in the context of the whole network of expectations that effect and are effected by them. All of the dotted lines represent pathways for mutually defined expectations. The points, in the center of the diagram, at which these pathways intersect, are the points of decision in the continuum of the discharge planning process from hospital back to community.

Let’s begin by pointing out a well known, but often forgotten, fact in the human relations field:

… the basic structure of all relationships is triangular.

That is to say, that the relationship between any two people, and, therefore, the expectations which define that relationship, always involve at least a third person or entity of some kind. This is the essence of the contextual nature of relationship.  Dyadic relationships are balanced and stabilized by their links to other aspects of their shared context. This third, balancing element in any relationship is used in at least two different ways:

First, we often, without even knowing it, communicate with one person through our interactions with a third person or entity.

Second, we balance our individual relationships through our interactions and involvements with other people or things in our context.

Looking at this diagram in terms of the triangular nature of relationships, we can examine this web of mutually defined expectations in terms of this triangular pattern and follow the discharge planning process form the beginning to the end along the decision line from hospital to reentry to community.

Prior to the onset of the illness and trauma, we presume that the patient’s relationship with his/her own family and significant others has been balanced and stabilized by his/her role in the larger community. When trauma occurs, the hospital, as the healing and “time out place” we discussed, temporarily replaces the community as the balancer of the relationship between the patient and his or her family system.

During this early stage of hospitalization, many of the mutually defined expectations for each other and the community are suspended by patients and their families with intense focus being placed on the issues of survival and reevaluating expectations about physical and, perhaps, mental capacity.

Consequently, the hospital, which means we as social workers and hospital staff, are the target of many very intense expectations from both the family and patient. These expectations, which may be experienced as burdensome and unrealistic, are not only about the medical/physical facts, but are the family and patient’s initial attempts at redefining their own relationships.

They need to use us in this way as a new, albeit transitional, entity to act as a balancer in their efforts to redefine totally new relationship with each other.

Many of the questions by patients and families about the state of the patient, present and future serve this purpose.

This critical need of patients and their families must be understood by the hospital staff if we are to provide an effective orientation leading to an optimum use of the hospital resources.   Here lies, however, potential for a major clash of expectations between the hospital and the patient/family system, which is crucial.

In this time of high pressure on hospitals about costs and efficient use of resources, patients and families are met by the hospital system with a fairly aggressive attempt to involve them in the hospital routine and gaining information the hospital needs to do its work. This focus is primarily on the biological repair aspects of treatment, and increasingly, on fiscal concerns and post hospital planning.  Patients when they are faced with this induction are forced to start working on the reality of their changed relationships before many of them feel they have adequate information or have been prepared to understand the process in terms of their own role.

Their expectations about what the hospital is supposed to be doing for them in this regard may not match what the hospital feels or expects of itself or them.

It is crucial that this initial difference in expectations to be identified and bridged, and patients be helped in this initial orientation process to understand theirs and the hospital’s role in the healing process.

If failure occurs in enabling the patient and family to use the hospital as the new balancer in their relationships, it is extremely disruptive both to them and to us.

Introducing discharge planning to patients at this early stage of hospitalization has to be done in the context of this orientation because they are simply not ready to begin rethinking about the community as the balancer without first putting the hospital experience in context of this process.

Discharge planning begins with this orientation process!

If we were to summarize the process of discharge planning in a hospital, we could say it is a process in which the patients and families are assisted in using the hospital environment as a temporary balancer of their relationship as they are gradually reoriented aback to the community in a way which takes into account he realities of the illness and disability.

The Crucible

The process is often difficult, uncomfortable for all involved and downright stressful. In this process, each of the entities we are looking at, patient, family, hospital and community, each of them puts pressure on all of the others in an attempt to accommodate and balance their relationships with the patient and the patient does the same.

The crucible of all this negotiating are the decisions that must be made and cannot be avoided: decisions about medical care, about allocation of resources, about whom and when people are going to do what. There is a genuine and needed process of struggle and dialogue between all the parties around these decisions and these decisions are what, in fact, redefine the expectations in the relationships.

As this process moves along the decision line from hospitalization to reentry to the community, it can be expected that patients and families will be experience increased anxiety and have difficulties in coming to grips with the limitations of what both the hospital and the community can offer them.  These limitations literally force them to restructure their relationships with each other in a way they would often prefer not to.

There are certain key elements needed if this decision process is to go reasonably well:

First, there must be adequate information available to all the parties.  Without this nothing can proceed.  We social workers and staff, the patients and families and the community need access to accurate and timely information.

Secondly, there needs to be stimulated and maintained with patients and families and, with ourselves, a creative open attitude towards problem solving and exploring new and different options.

Thirdly, there needs to be recognized and supported the need to struggle with each other, push and pull, speak frankly and define limitations as well as explore options.

Fourth, there needs to be on our part as social workers, a willingness to advocate and explore ways of creating new options in the facility and the community that may be able to accommodate the unique needs of the patient and family.

The role of the social worker

The social worker is like an octopus sitting on this chart with tentacles reaching out to each and all of the elements in this process of negotiation.  The social worker’s power to integrate this process lies with his or her task:

to bring a plan to life, through this process of dialogue, negotiation of expectations and decision making, that will reintegrate the patient back into the community and reestablish the community in its role of balancer and stabilizer in  the relationships between the patient and family,

Discharge planning is not about getting people out. It’s about getting them back.

* Excerpt from Soundings: Exploration of social work in a changing health care environment. New York: South Garden Press. 2009.

©  2009 James Donnelly, DSW.LCSW

All rights reserved

South Garden Press, New York

For thoughts and comments, please e mail to: jdonnellydsw@gmail.com