Discharge to home after SCI is highly complex with
needs including accessible housing, home modifications,
equipment, supplies, medications, and therapy services.
Successful home discharge requires the social worker/
case manager to educate the patient and family about
accessible transportation, housing options, waiver programs
to fund services such as homecare or home modifications,
and local and government financial resources;
the social worker/case manager also assists with completing
appropriate applications. The association of
SW/CM time spent on financial planning and community
services with home discharge is indicative of how
important such planning is to discharging patients to
home as opposed to alternative settings. When the
need for discharge to a location other than home, typically
a nursing home, is determined, discharge efforts
are expanded to include planning for this alternative
type of discharge, and indeed, we see associations of
more time spent on planning for discharge to aassociated with less likelihood of discharge to home. The
association of the number of sessions dedicated to discharge
planning and services with discharge to home
and other outcomes is probably due to the fact that
most of these services are addressed with all patients
while time is spent on planning for a discharge to a
location other than home only after home discharge
has been explored and determined to be unsafe or otherwise
not feasible.
More sessions focused on planning for discharge to a
location other than home, along with other SW/CM
interventions had many associations with societal participation.
The association of more sessions spent on
planning for personal care services and discharging to
alternative environments with lower social integration
scores may signal a need for greater intervention to
improve societal participation, or we could infer that
when patients do not live at home or require much personal
care services in the home, their ability to spend
time with family, business associates, or friends is diminished.
Other negative associations were also seen, for
example, more time spent addressing barriers to discharge
was associated with greater likelihood of rehospitalization.
It may be that these interventions provide
benefits to the patients and families who need them.
Typically, patients who need more assistance with
addressing barriers and improving accessibility would
be those patients with limited mobility, which could be
associated with greater likelihood of rehospitalization.
Thus, negative associations should be interpreted with
caution, and not necessarily as ‘bad’ but rather may be
an indicator of patient need.
It is astonishing to see positive associations between
more time spent in classes led by SW/CM with several
outcomes (higher CHART physical and social integration
and less rehospitalization). Perhaps the learning
that occurs in these classes can be used by the patient
and family to manage low-risk medical situations for
which care may otherwise be sought in a hospital
setting. Further research is needed to determine benefits
of SW/CM classes and other forms of education as well
as the most effective ways to deliver such information.
In addition to examining the associations of SW/CM
interventions with outcomes, it is also interesting to
discuss the influence of primary payer. Medicaid as a
payer was associated with lower CHART Social
Integration and Mobility scores, a smaller likelihood
of working or being in school at the 1-year anniversary,
reporting lower life satisfaction, and greater likelihood
of rehospitalization after discharge. Medicare was
associated with more rehospitalization and reporting
of pressure sore at the time of the anniversary. Thus,
Medicaid and Medicare as a primary payer source
appear to be a marker for worse outcomes. Persons
who qualify for Medicaid benefits have limited income
and assets, and thus, may have limited access to
resources and may live in an environment less conducive
to satisfying their needs. Persons with Medicare tend to
be of an older age and/or have more complex medical
conditions (co-morbidities). Payer type is indicative of
socioeconomic status and age, which may influence
educational and employment opportunities, as well as
access to high-level technological devices (environmental
controls, computer technology), personal transportation
(accessible van), leisure pursuits involving
costly high-tech equipment or additional costs, and
travel. While a majority of third-party payers provide
benefits for skilled services in the home (intermittent
nursing visits and therapy services), both Medicaid
and Medicare recently have begun imposing limits on
the amount of services provided. There also may be
access to care issues for patients covered by Medicaid
or Medicare as some health care providers may not
accept the lower Medicare or Medicaid reimbursement
for services.
nursing home or alternative living environment to be