30 Day Cliff Post Discharge

The 30 day cliff…..

The is the month after discharge from a healthcare facility when patients are at high risk for death, injury, or readmission to the hospital.

As a physician I have planned thousands of discharges. 

I have sat in a seemingly infinite number of multidisciplinary rounds.  

My fiance was recently hospitalized and had subsequent complications not related to the surgery.

Most of the doctors that cared for him prior to discharge are colleagues I knew from prior employment, I like and respect them.  I appreciated their expertise, warmth, and effort for his well being. 

Several other physicians during his hospitalization were new to us but as skilled, knowledgeable, and empathetic as the physicians I have known for years. 

Nurses, nurse techs, physical therapists, and occupational therapists invested in his recovery. 

He has an amazing Primary Care Physician working with a stellar RN coordinator that helps with transitional care medicine.  He had a follow up appointment within 7 days of discharge.

He and I have a strong, respectful, and loving relationship.  

He is able to verbally communicate his caregiving needs. 

I am a willing and dedicated caregiver. 

He was in the military.  I completed medical training. We understand how to persevere in adversity and be resilient. 

Even with all of these positive facets to his care we have danced on the edge of the 30 day cliff. 

Struggling to get wound care supplies from home health nursing, even though his insurance covered it 100%.  

It took over a week, multiple phone calls, and in the meantime we ordered them online with out of pocket money and next day delivery. 

Getting a new filter for his suction machine that removes respiratory secretions from his airway took 5 days and several phone calls. 

Constantly calculating exquisite mathematics and physics to keep us from falling off that cliff.  We are dizzy from looking over. 

I see how patients “bounce back” to the hospital, begging for services they qualify for while fighting short staffed agencies with burned out employees. 

They are then labeled as failing at home and get warehoused in a facility. 

This is with good insurance coverage, an incredibly pleasant and grateful patient who is able to verbalize his needs, and a supportive family with decades of healthcare literacy. 

How can we expect others to navigate the system while exhausted and recovering, let alone survive?