Going Above and Beyond to Ensure Safe Patient Discharges

From the outside looking in, it might seem like patient care stops once an individual leaves the hospital. But members of Alice Hyde’s inpatient care team – nurses, aides, therapists and more – know that patient care never stops, the focus of that care simply changes.

Regardless of whether a patient is preparing to return home, enter a long- or short-term care or rehabilitation facility, or explore alternative living arrangements with family or friends, the hospital’s discharge planning team plays a central role in ensuring patients are transitioning into a safe and supportive environment, and have the resources they need to meet their health and wellness goals.

Coordinating those critical elements of each patient’s departure from the hospital is what Amanda Hanna, MS, MHA, a social worker and case coordinator on Alice Hyde’s inpatient care team, does every single day. And while many, if not most, patients have a relatively smooth transition out of inpatient care, it is Amanda’s dedication to and advocacy for patients in more difficult circumstances that has endeared her to colleagues on Alice Hyde’s Medical-Surgical Unit.

It’s also what prompted one colleague to nominate Amanda for Alice Hyde’s first-ever BEE (Being Extraordinary Everyday) Award – with which she was honored earlier today.

“She so deserves it – Amanda is everything the BEE award is all about,” said Heather Norcross, RN, a registered nurse on Alice Hyde’s Medical-Surgical Unit who has worked with Amanda since she joined the hospital in 2015, and nominated her for the award.

Norcross said that Amanda’s compassion and dedication is on display every day – but it wasn’t until several months ago, when the Med-Surg team began caring for a patient who had undergone a severely traumatic experience, that she understood the true strength of Amanda’s commitment to ensuring every patient can transition from the hospital into a healthy, safe and supportive living arrangement.

Norcross said that at the beginning of the patient’s hospital stay, many weren’t even sure they would survive due to the extent of logistical complications and health challenges facing the patient and their care team. Despite the team’s concerns, after several weeks in Alice Hyde’s Intermediate Care Unit, the patient found themselves on the road to recovery.

As the team began attempting to plan the patient’s discharge from the hospital, Norcross said, another challenge emerged.

“It was basically our worst-case-scenario,” said Norcross. “Somehow, there was nowhere for them [the patient] to go.”

While difficulty finding timely placements for some patients is routine, Norcross said, this case was exceptional, with logistical, legal and other issues slowing the process and severely limiting the available options for getting the patient into an acceptable living arrangement. Through it all, Norcross said, Amanda refused to give up hope – or stop using every resource available to her to get the patient into the situation that best suited their needs.

“As time went on, I think it was traumatizing for all of us,” said Norcross. “Somehow, with everything Amanda does and knows, and her contacts and knowledge of the rules and laws, she made it happen.”

Even for a case manager of Amanda’s skill and knowledge, the effort took nearly nine months, Norcross said, with multiple false-starts and potential resolutions that ultimately failed to materialize.

“It’s just really hard to explain how hard it is, if you’ve never been admitted to a hospital,” said Norcross. “Imagine spending nine months in the same single room. We were all so happy that Amanda found a place that was going to let our patient explore their world and get the services they need.”

These days, members of Alice Hyde’s inpatient care team still visit the patient and keep in contact in various ways – and have many thanks for Amanda, for going above and beyond to ensure the patient continues to walk their own road to recovery.

“There’s just so much that Amanda does that we don’t even know – don’t even see,” said Norcross. “It definitely doesn’t go unnoticed. She’s a tremendous asset to us, and to our patients.”