Care, No Matter Where
Whether in your personal life or your healthcare career, you might notice when an individual's medical needs and functional status are beginning to become more difficult to manage. We can see this in the suddenness of a new injury or through the evolution of a chronic or degenerative illness. At a certain point, it can become so difficult to live with a health condition that the living environment needs to change to better tend to one's specific needs. When one's care needs begin to exceed the support available in a current environment, we refer to this process as "phasing out" of a living environment. We want to provide guidance to ensure a smooth transition as you "phase in" to your new living environment to support both you and the community.
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How does phasing out impact the community and the individual?
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The individual may become at risk for more healthcare complications if they're struggling to obtain services
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Their home care agencies may cease to provide services if they find the patient a risk at home
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Landlords, motel owners, and shelter directors may be forced to dismiss the individual from their facilities
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Hospitals might admit patients without medical necessity in order to assist with transitions of care, therefore limiting the beds available for those who medically need it.
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When individuals start to "phase out" of their current living environment, they can be at risk of losing the most important resource they have -- their housing.
Quite often, we can see this potentially downward spiral in its beginning stages, and all that is needed to mitigate and prevent these outcomes is consistent support alongside the individual experiencing a transition.
bout 7 years into my time as a medical social worker, I met a patient on one of the medicine wards. He had a history of congestive heart failure and had been homeless most of his life. He was in the hospital for a spinal cord injury. We had met during the pandemic and while he lay in his hospital bed, we spoke of how his world had changed. He could not walk or do his ADLs and how the world around him was changing. I worked him in to find him a suitable nursing home to convalesce and strengthen. He made great progress there, but eventually, with his new ability to walk, decided to check himself out.
Each time he visited the ED, he was discharged a few hours later....
After he left the facility, he went back to the shelters, but his health slowly started to decline. His oxygen needs increased, his walking got slower. And he started visiting the ED. Each time he visited the ED, he was discharged a few hours later. When he was found cold and on the streets, he was brough back to the hospital. Over the course of two months, he had 38 ED visits. Frank was caught in the same cycle as many patients: He could not fully take care of himself on the streets or access a higher level of care, prompting repeated return visits to the hospital. But at the hospital, he did not meet the medical criteria to be admitted, though he would have the support in the hospital to access a higher level of care. He did not have a phone to schedule a PCP appointment – which were scheduled a month out. I spoke with Frank I advised him to stay at the shelters; I would stay on his case and remain in communication with him as I tried to locate a care setting that met his needs. Within the next eight days, a care facility agreed to accept him, and through collaboration with the shelter system, he was admitted as a resident to a new nursing home. His emergency department visits decreased the following four months – he had only 4 medically indicated ED visits.
Along the way, a trusting relationship formed between me and Frank. He would call me to let me know how he was doing at his facility; I would contact him to check-in about any concerns or needs. I collaborated with his primary care team to ensure transitions of medications and access. All it took for Frank to get the care he needed was an anchor in the community to follow his case and offer hope that the support exists. New Phase Navigation provides a way for individuals experiencing healthcare changes to receive support in a multi-system approach while providing solutions for individuals, families, or healthcare providers.