Hospital Admission: How to Plan and What to Expect During the Stay

Doctors (Physicians)

If your family member is a patient at a “teaching” hospital then you are likely to meet many doctors and medical students. Feel free to ask each doctor his or her name and level of training. You should also ask who is in charge of your family member’s care. Doctors can include:

• Attending Physician (“Attending”). This is an experienced doctor who is in charge of your family member’s treatment plan. He or she works with and supervises other doctors treating your family member.
• Hospitalist. The attending physician may be a hospitalist, an experienced doctor who takes care of patients throughout the hospital admission but does not see patients outside the hospital. The patient’s primary care (“regular”) doctor will probably not come to the hospital. You should ask the hospitalist or other attending physician to be in contact with the primary care doctor. For more, see the Next Step in Care guide What Is a Hospitalist?
• Fellow. This is a doctor who is getting advanced training in a special area of medicine.
• Resident. This refers to a doctor who graduated from medical school two to three years ago. Residents are being trained in special areas of medicine. A “senior” resident is in charge of “junior” residents and interns. They are supervised by the attending physician.
• Intern. This is a new doctor working under the guidance of residents and the attending physician.
• Consultants or specialists. The attending physician may ask other doctors to help diagnose or treat your family member. For instance, your family member may be seen by a cardiologist who is a specialist in heart disease or a neurologist who knows a lot about strokes.

Other health care team members (not doctors)

It is likely that there will be many other health care professionals on the health care team. Nearly every hospital will have the following professionals on staff:

• Registered Nurse (RN). Nurses perform health assessments, give medications, monitor (check) vital signs, change wound dressings, provide wound care, and teach family caregivers basic skills to care for the patient at home. You may see new nurses each day as most work in 8- or 12-hour shifts. The nurse is often the best person to talk with if you need something or have a question.
• Nurses’ aide or nursing assistant (NA). These team members work under the supervision of RNs. Their job is to take blood pressure, change bedding, assist patients going to the bathroom, give baths, and help make sure patients are clean and comfortable. They work in shifts (like nurses) and you may not see the same aide each day.
• Social worker. The social worker assesses the needs of each patient and family. He or she helps with health insurance problems and, as needed, plans for social or psychological services. The social worker is often the person that helps with discharge planning. This includes transportation home or to another facility as well as referrals for care after discharge. You can learn more by reading Leaving the Hospital and Going Where?.
• Medical technologists, radiographers, and nuclear medicine technicians. These technicians take blood and perform X-rays and other tests.
• Dietitians (Nutritionists). They provide counseling and assessment about nutrition (food and diets).
• Patient Representative. This person helps resolve complaints from patients and caregivers. These complaints may be about the quality of care, hospital policies and procedures, or conflicts with hospital staff. Patients and family members can ask to meet with the Patient Representative.
• Chaplain. Hospitals have specially-trained clergy (religious leaders) who provide pastoral care and talk with patients and their family members. You do not need to belong to an organized religion or be religious to speak with a chaplain.
• Escorts/Transport. These workers take patients for tests and procedures within the hospital. Sometimes it takes a while for escorts to arrive as they can be very busy. You may want to go with your family member to all tests and procedures.

Depending on your family member’s condition and care, other staff members may be involved:

• Nurse practitioner (NP). This is a registered nurse who holds a master’s degree and received advanced training. He or she is certified to treat many common illnesses, take a patient’s medical history, order tests and prescribe therapy and medication (in most states).
• Physician’s assistant (PA). This person is supervised by a doctor. PAs can take a patient’s medical history, order tests and prescribe therapy and medication (in most states).
• Therapists. They include: physical therapists (PT) who help patients with walking and regaining strength; occupational therapists (OT) who help patients with skills like eating, getting dressed, and using assistive devices; speech therapists (SLP) who provide specialized care as needed.

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Here are some ways you can help:

• Help make sure that your family member gets the treatments needed. You can do this by checking with the nurse going off duty and asking what needs to happen during the next shift. This includes medications, tests and procedures. You can make sure the nurse coming on duty next has the same information.
• Ask questions about your family member’s medical condition, treatment, and follow-up plan of care. It is a good idea to write questions as you think of them. This way, you will be prepared when meeting with the doctor, nurse, or other health care professional.
• Keep track of all instructions and plans for discharge. A good way is to write this information in a notebook and keep it by the bedside.
• Tell the doctor or nurse if you do not understand something or want to learn more about a certain topic.
• Let the doctor or nurse know if you do not feel ready to care for your family member after discharge.
• Use good communication skills. This means listening carefully, speaking clearly, and using a friendly tone.
• Ask to speak with the doctor, nurse, social worker, or patient representative if feel there are communication problems with the staff or you or your family member are not being treated fairly.

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Hospital Admission or Observation Status?

Just because your family member is in a hospital bed, on a hospital unit, eating hospital food, and undergoing hospital tests does not automatically mean that he or she has been admitted to a hospital. Sometimes doctors want to watch a patient for a few hours or a day to see whether there is really a need to be admitted to the hospital. This is called “observation.” More patients are now in hospitals being observed rather than admitted. This is largely because of Medicare’s efforts to reduce expensive hospital admissions and possible readmissions.

Does it matter if your family member is admitted to the hospital or is just being observed? Yes, because Medicare pays for hospital admissions and observation differently. As a result, your family member’s part of the bill is likely to be higher if he or she is only being observed than if he or she were actually admitted.

There’s more. To be eligible for Medicare-covered skilled nursing facility services, your family member must have been a hospital inpatient for at least three days. The observation days do not count.

The result? After 72 hours of observation, your family member will have a higher hospital bill and will not be eligible for Medicare-paid rehabilitation services in a skilled nursing facility. Note that these rules apply to regular (that is, fee-for-service) Medicare; if your family member belongs to a Medicare Advantage (HMO) plan, check with the plan for its requirements.

What can you do?

• In addition to all your other questions, ask repeatedly, “Has my family member been officially admitted to the hospital, or is he or she under observation status?” Your family member’s primary care doctor will probably not be involved in this decision.
• Make a note of each staff person’s response, including the name and date.
• The hospital can retroactively (after the fact) change the patient’s status from inpatient to outpatient. This change is supposed to be made while the patient is still in the hospital, with a written notification to the patient.
• If you do not receive this notification, or if you want to appeal the decision, you can contact the Beneficiary and Family Centered Care-Quality Improvement Office (BFCC-QIO) at http://www.nextstepincare.org/Links_and_Resources/Federal/Medicare_Appeals/.

Medicare has issued a brochure that explains observation status.
http://www.medicare.gov/publications/pubs/pdf/11435.pdf

Also see the Center for Medicare Advocacy website.
www.medicareadvocacy.org

Financial (Money) Issues

For a planned hospital admission, contact your family member’s insurance company before the hospital stay. You need to do this because most insurance plans require “prior approval” – when the insurance company agrees to pay for the hospitalization before your family member is admitted.
For an emergency hospital admission, call your family member’s insurance company as soon as you can. If the hospital admission has been planned with a doctor’s office, someone there will help make sure approval has been granted. Let this person know if you have any insurance problems.

Learn about your family member’s insurance. This includes what it will and will not cover (pay for). This helps you prepare for any additional costs. Speak with the hospital account representative if your family member does not have insurance or if insurance does not cover all the costs. Also let the account representative know if your family member cannot pay the costs. The hospital may be able to get you financial assistance or arrange a payment plan.

Delays

There may be times when your family member’s tests or procedures are delayed (late). This happens because hospitals can be very busy. Be patient and ask the nurse to tell you when this test or procedure might take place. Remember that the nurse may not be able to control the schedule.

Quality of Care

You may have concerns about the quality of your family member’s care. Perhaps you think that there is too much care (such as too many tests, too many consultants, or too many medicines). Or maybe you are concerned about too little care (such as few doctor visits, unclear plans, or information that changes from person to person).

Here are some common quality concerns along with what you can do:

• If you feel your family member is being discharged before he or she is ready, you have the right to ask for a review of this decision. Let the nurse or case manager know about your concern and your wish to have the decision reviewed.
• If you are concerned that your family member is getting care that is of poor quality, not well coordinated, or unsafe, tell the doctor or nurse.
• If problems are not solved, you can make a formal complaint through the Patient Representative or Senior Administrator “On Call.”
• If problems are still not resolved, you can contact the Beneficiary and Family Centered Care-Quality Improvement Office (BFCC-QIO) at http://www.nextstepincare.org/Links_and_Resources/Federal/Medicare_Appeals/.

If Your Family Member is Confused

Many patients become confused when in the hospital. This happens even more when patients are older, have had a stroke or brain injury, or are in the ICU. Even though it is common for patients to be confused, do not ignore it.

Family members are often less confused when caregivers stay with them. Caregivers can help explain what is going on and offer comfort. Let staff know if your family member seems more confused. They likely can find ways to help.

If Your Family Member has Alzheimer’s or Other Form of Dementia

A hospital stay may be especially difficult for people who suffer from Alzheimer’s or other forms of dementia. These patients are likely to feel disoriented, confused and anxious in an often chaotic environment such as the hospital. They may be upset by an unfamiliar routine and care by strangers. Be sure to let hospital staff know any helpful tips about feeding or bathing your family member. Also let them know if your family member has problems such as wandering, shouting or other aggressive behaviors and how best to cope with such behaviors. It might help to remind staff that looking directly at your family member, and talking in a calm and reassuring voice will help reduce anxiety. For your part, make sure you orient your family member to the hospital surroundings as often as you can.

Words You Do Not Understand

Health care professionals often use special language (“jargon”) when talking to each other. This may save time but can be very confusing for patients and family caregivers. This includes terms as “PEG” (a feeding tube inserted in the stomach) and words like “febrile” (having a fever).
Ask what these words and terms mean. Don’t be embarrassed. Many people have trouble with jargon. Here is a way to learn about common medical terms, click here: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html

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