Continuing care after hospitalization

photo of willie smith talking to social worker shonda knox

According to hospitalist Willie Smith (here with social worker Shonda Knox), the hospital stay sometimes seems like the least complicated part of what a patient needs to keep doing well.


Emory University Hospital Midtown

Before Myra Collins arrived at Emory University Hospital Midtown’s emergency room, she had been living in a personal care home. An aunt checked in on her regularly, but Collins required more care than she could provide. The 48-year-old woman could barely see, was hard of hearing, and had moderate cognitive disability.

At Emory Midtown, she received swift, textbook-perfect treatment for rectal cancer, including surgery and chemotherapy. Collins seemed to settle in. She smiled when doctors and nurses asked her how she was doing, and she responded to the warmth and patience of the nurses teaching her about her colostomy.

Soon, she was in stable condition. According to protocol, she was ready for discharge, with the need to return for daily outpatient radiation and follow-up on her colostomy. But her care team did not believe, given her challenges and the limits of the personal care home where she had been living, that she would be able to manage logistics of transportation, appointments, and colostomy care. Her case was presented at the hospital’s Complex Patient Care Committee, headed by Willie Smith, medical director of care coordination. The committee, consisting of various clinicians and social workers, routinely sees patients like Collins whose complex personal situations create “barriers to discharge.” The committee works hard to find ways to overcome these barriers and ensure all patients have a safe discharge back into the community or to another level of care.

After hearing Collins’ case, the committee decided she could leave the hospital—but not return to where she had been living. Oncology social worker Shonda Knox arranged a six-week stay in a closer, more experienced personal care home. She also coordinated transportation for Collins’ various medical appointments. Medicaid and Medicare had paid Collins’ medical costs while she was an inpatient. But from the moment she checked out, housing, transportation, medical, and other costs all were paid by Emory Midtown. The hospital arranged for Collins to receive mail-order colostomy supplies at no cost and is now working with Collins’ relatives to see if Medicaid/Medicare will agree to let her stay in the personal care home that has been so helpful. It’s all part of getting patients well.