Placement and Dispo

The biggest frustration of being at San Francisco General Hospital is figuring out where patients go after their acute medical issues have resolved. We see so many homeless people, drug users, illegal immigrants, psychiatric patients, and people without insurance that we have armies of social workers to figure out how to "place" people. If they don't have a home or have a nursing need, where do they go? This is an important issue. The longer people stay in the hospital, the more the likelihood of an "iatrogenic" (or doctor-caused) problem. The hospital is filled with antibiotic-resistant bacteria, being in bed all day causes pressure sores, having an IV can lead to infection of the veins. So once patients are better, they need to leave. This also touches on the shortage of resources; patients without a medical necessity but have problems with discharge planning often take beds that need to go to those with medical illnesses.

In my rotations at SFGH, I've noticed how difficult "dispo" (disposition, that is, post-hospital plan) can be. On neurology, we had patients who had been in the hospital for a year without acute medical necessity simply because their insurance status doesn't allow them to go to the type of nursing facility they need (they had a tracheostomy which can be cared for at some skilled nursing facilities, but none that took their insurance). On our service now, we have patients who are undergoing the weeks-long process of being conserved (appointing a legal decision maker because their illness makes them incapable of making medical decisions). We have a patient who has too much money to leave the hospital (I'm not sure of the exact details, but he has mutual funds or bonds that he won't liquidate and he can't leave the hospital to a Board and Care until he qualifies for Medi-Cal). We have a patient from San Jose who is waiting for a bed down there to be transferred. The social workers, case managers, and utilization review here are fantastic, but the challenges are immense.