A Problem of Capacity, but Whose? The Hospitalists' Discharge Dilemma and Social Determinants of Health

Abstract

For a number of years, those challenged with improving discharge transitions and preventing readmissions have suggested more-more case managers, more checklists and systems, more discharge pharmacists; and better-better communication, better medication reconciliation, better discharge documentation, better follow-up. In a study by Chan Carusone et al., 1 high-need, high-complexity patients receiving treatment at Casey House, a specialized urban hospital providing inpatient and community programs, were afforded a full complement of discharge planning and posthospitalization services. Despite these services, the patients achieved little success in maintaining their health and following their discharge plans after hospitalization.This longitudinal qualitative study detailing the lived experience of discharge extends our knowledge of challenges faced by patients during the posthospital transition, 2 and further elucidates the differences between patients' expectations and assessments of their resources and goals, and their actual abilities and priorities on discharge. Despite substantial assistance, including housing, food assistance, and case management, Chan Carusone et al. found that the exigencies of day-to-day existence exceeded the patients' capacities to sustain themselves outside the hospital. This failure implies a question: If the interventions alluded to in this study were not enough, then how much more, and how much better, is needed?Attention to this question of how to best serve high-need patients continues to increase, 3 and success in intervening to improve care transitions for this population is limited, 4 in part because providing more care and more coordination requires more resources. Observing the challenges that remain for patients treated in the highly-resourced setting that is Casey House, the authors propose a previously described theoretical construct, minimally disruptive medicine (MDM), 5 as a framework to guide patients and providers in creating a discharge plan that relies on the patient's capacity to integrate disease self-management into his or her daily circumstances. MDM hinges on the concept of balancing workload and capacity: the burden of managing disease