Happy start of the school year! Perusing social media, I came across a NASW blog article called “Guide for the First Year Social Work Student”. This post provided lots of great information tailored for new undergraduate students interested in studying social work.

I wanted to take that NASW post a bit farther and compile a list of tips specific to graduate students pursuing a masters in social work (MSW). In my opinion, graduate school is a completely different experience from undergraduate, so my hope is that these tips will serve to be beneficial.

Tips for New Social Work Graduate (MSW) Students

-Don’t worry about grades so much

When I was in graduate school, one of my professors told a story about a straight A student who committed suicide several years after graduation. His point was that given the people we need to work with, we social workers need to focus less on being perfectionists (as demonstrated by obsessing over grades and test scores) and work on being empathetic and competent practitioners. Indeed, some of the WORST social workers I have worked with were those who claimed on their resumes to have graduated with honors or perfect grades. 

Unless your intention is to get a PhD or DSW, you do not need to get straight As. Grading in graduate school is easier, and that is due to the assumption that most graduate students are mature enough to take responsibility for their learning. Don’t focus on “what’s on the midterm” and instead pour your energy into learning and becoming the best practitioner possible. I guarantee that you will still pass your classes and end up a better social worker as a result.

-Network with your classmates

This is not law school or medical school. Your classmates are not your competition (see above in Don’t worry about grades so much). Unlike other fields of study, social work is extremely collaborative which is reflected by curriculum, which will be discussed below in Prepare for many group projects.

Social work is a small world. Many of your classmates will end up your future coworkers. Some of them may even end up your managers someday. Network with and befriend your classmates and internship colleagues. You’ll have textbook swap and study buddies, friends to unwind with on Fridays, and people who will tell you about job openings someday.

-Prepare for many group projects

I can guarantee that you will have a group project in each of your classes. This makes sense because social work is a collaborative field, and we will spend our careers working with fellow social workers and other disciplines. While many groan at the idea of group projects (I know I do), this is a perfect opportunity to practice collaboration and potentially conflict resolution skills. Who knows, you might make some friends! I have fond memories of late nights with classmates eating snacks and celebrating after completing a project.

-Go to office hours

I found many of my graduate school professors extremely approachable and understanding, which makes sense because most of them are social workers. If you’re having trouble grasping certain concepts or simply want to chat about issues pertaining to social work, then go to office hours. This is a great way to get extra help and develop a working relationship with a professor. They might even give you useful career advice or a letter of recommendation for that PhD.

-Invest in some good work clothes

None of my jobs in undergrad required formal attire. Going into grad school, I basically owned two pairs of ill-fitting slacks and a blazer. In fact, I recall meeting with my internship coordinator wearing a floral skirt and a tank top - hardly business attire. Afterwards, I spent the first weekend of graduate school shopping for new work clothes. 

In my opinion, a few pairs of slacks, a blazer or two, blouses, and a pair of COMFY shoes (especially if you have a hospital internship) should suffice for graduate school internships. Given that you’ll be spending 8+ hours in these clothes, I recommend something that’s comfortable and of decent quality. While my wallet was screaming after buying all these clothes, I continued using them for post-MSW job interviews and jobs. 

-Read up on current events

Social work and current events go hand in hand. In many of your classes - especially policy - you’ll have class discussions on current events and how they relate to the material you’re studying. Read the news and familiarize yourself on various news sources across the political spectrum (even if you don’t agree with what they say). It's good to learn about various political arguments and why people have them, as at some point you'll likely end up working with and coexisting with colleagues and patients with viewpoints contrary to your own.

Furthermore, I cannot emphasize enough the importance of paying attention during social policy class, specifically the part when you study the NASW Code of Ethics. Too many social workers ignore or forget their Code of Ethics, causing them issues later in their careers. Our Code of Ethics is like the physician’s Hippocratic Oath. Learn it and ingrain it in your mind.

-Speak up in class

I'm not only saying this because many social work schools grade you on class participation. This is good practice for speaking up against superiors to advocate for your patients (and yourselves). As someone who spent undergrad hiding behind my laptop, I made it a personal goal to speak up at least once per class meeting.

-Get familiar with your school library

While I never used my school’s library to study, I went there frequently to check out textbooks. This saved me hundreds of dollars in book costs. Familiarize yourself with library services such as interlibrary loan (my favorite), course reserves, and academic journal access. It could save you a lot of time and money.

-Find a favorite place to study

As I’ve previously, I never studied in the library, as it was too quiet for my tastes. In graduate school, my favorite place to study was a cafe next to a light rail station. While many people did not like the noise, distraction from the train, and smell of coffee, I always seemed to get the most work done there. Every person is different and thrives under varying environments. Experiment by studying at different places and find one that works!

-Don’t forget self-care

Graduate school is busy and exhausting on its own. Many of us have to balance work and family responsibilities on top of that. Make sure to take a little bit of time each day for yourself, even if this means going for a walk or taking a long bath. One of my favorite things to do was get happy hour appetizers and unwind with my classmates after class. Developing those self-care skills now will help combat burnout and increase longevity in this stressful field.

Do you have any other tips for new social work graduate students? Please comment below!

To all the new social work graduate students out there, congratulations again on starting your MSW and joining this noble helping profession. Best of luck this year!

Why I Want To Leave Social Work

It's been a while since I've updated this blog. I actually wasn't sure if I would actually come back to it, but given recent events I have some free time on my hands and should keep occupied. With that said, let's cut to the chase.

I'm burned out. After 10 years of being a social worker, I'm ready to leave the field. A few of the reasons are as follows: 

1) Emotional and physical exhaustion 

As we all know, social work is an extremely demanding job with high caseloads, emotionally taxing situations, and strict deadlines. Depending on how busy I am and how much caffeine I've had, I'm usually running on high alert so I could finish everything by the end of my shift and sit in traffic. Being in a continual state of stress has started wearing on me, and I find that as I age I'm not as physically and emotionally resilient as I used to be.  

The social work profession promotes self-care as a way to prevent burnout. This is nice and all, but how can you take care of yourself when you simply don't have the time, energy, or money to do so? This leads me to my next point: 

2) Unfair compensation 

Early in my career, I worked in a hospital where social workers and nurse case managers essentially did the same discharge planning functions. In addition to my social work duties, I was also responsible for arranging skilled nursing home placements, home health visits, ambulance transport, and durable medical equipment for patients. There were even instances where I had to arrange acute-to-acute transfers and helicopter transportation because there were no nurse case managers around at the time. This is fine. 

However, what is not okay was that I was paid significant less than nurse case managers. When I say significantly less, I mean up to 50% less for doing essentially the same job functions. Considering that a hospital social worker job requires a minimum of a masters degree, it's basically saying that a MSW is worth half a RN. While I've learned to accept that social workers with masters degrees are paid less than nurses with associates and bachelors degrees, is our graduate education really worth HALF as much? 

Furthermore, all of these professions (which only require an associates or bachelors) all pay higher than a social worker with a masters degree: nurses (RN and LVN), physical therapists, occupational therapists, nutritionists, respiratory therapists, medical laboratory technicians, speech therapists, radiology technicians, pharmacy technicians, etc. I realize that all of these hospital professions are important. I also realize that I should be thankful that I'm paid as much as I am as a medical social worker. However, social workers are important too (see "Dependencies" below). It's incredibly demoralizing that we have to get masters degrees (plus an extra two plus years on top of that for licensure) just to get paid less than people who didn't have to be in school for as long. 

Like other "Healthcare Heroes", social workers are also on the front lines. I've read multiple stories of social workers who comfort COVID-19 patients, including facilitating numerous "farewell" conversations with family members a day. Hospitals, health clinics, social service agencies, APS, CPS, etc. - they don't shut down because there's a global pandemic. We are out there serving, and some of us are dying as a result. We matter, and the fact that we are grossly underpaid and not acknowledged for our contributions (I was refused a "Healthcare Worker Meal" at a fast food restaurant because my badge only said "Medical Social Worker") is a travesty.

While I see things ever so slowly changing for the better, the NASW and social work profession in general has run on a martyr complex for too long. The mindset of "we didn't go into this for the money" has resulted in generations of social workers tasked with caring for others yet horribly underpaid. Self-care? That's cute, but not when many of us struggle with paying for our student loans and basic living expenses. 

3) Lack of respect

Most hospital professionals don't realize that medical social work requires a masters degree for an entry-level job. However, they realize that we 1) don't have extensive medical knowledge (since we went to graduate school to learn about social work and the psychosocial perspective, not the details of human medicine) and 2) don't get paid well. As a result, we are viewed as and treated like we are stupid. 

When I first described my job duties to my boyfriend-now-husband, he stated that it sounded like "glorified secretary work". Initially, I was so infuriated that I nearly broke up with him. Years later, as the nurse case manager ordered me to make copies of yet another chart to fax to a home health care agency, and everyone at work started viewing me as clerical help because of the number of hours I spent at a copy machine, I couldn't help but think that he was right. 

 No matter how I tried to educate my non-social worker colleagues about my scope of practice, nothing seemed to help with regards to how they viewed social work. My pay certainly didn't go up to match that of nurse case managers. I was viewed at as one of the "good social workers", who got her work done quickly, efficiently, and on time. A few coworkers even commented that I was "too good" or "too smart" for this job, which seemed to insinuate the view that social workers are less intelligent than those who go into STEM fields. 

Outside of work, family acquaintances would express shock at my parents that I went into social work. Those who work in hospitals basically assumed that I did paperwork and clerical work all day instead of clinical work. One nurse even mocked me for the lack of math classes in my masters program (to which I responded that I took calculus as an undergraduate). 

Eventually, I changed jobs and went to a hospital that seemed to have a better understanding of social work's function. While I wasn't necessarily getting paid any better, I also no longer had to do discharge planning clerical work. I suppose this helped keep me in the field a few extra years, but if everyone is going to think negatively of what I do anyway, I might as well do something that truly makes me happy. As I have told close friends, social work is my calling, but it's not my true passion in life. 

4) Dependencies 

"Dependencies" is a term I stole from my husband, who is a software engineer. He uses it to refer to the various groups he relies on for his work projects. This parallels to my job in that what he calls dependencies is what we hospital workers refer to as the interdisciplinary team model. This is where the different health professions (i.e. physicians, nurses, nurse case managers, physical/speech/occupational therapists, pharmacists, and social workers) communicate and function in tandem with the intention of providing quality care and safe discharge home. 

In terms of discharge planning, this includes nurses assessing patient needs, physical/speech/occupational therapists making recommendations for discharge needs, physicians writing orders/prescriptions for the appropriate interventions, and nurse case managers or social workers arranging everything. If any discipline drops the ball, the entire discharge falls through. 

When I actually did discharge planning, I wasted literal HOURS waiting for other people to finish their parts of the discharge. One example is waiting for physicians to write orders (because I can't get do anything unless I have a doctor's order), or waiting for them to call me back after leaving a voicemail message. Often, I would fax, email, or leave important forms or requests for letters in the chart, along with a phone call and note requesting for them to get it done by a specific date/time. More often than not, my email inbox would stay empty, my fax machine quiet, and papers in the chart blank.

As a result, I'd end up filling out the forms or writing the letters myself because I was running out of time. Yes, me, a lowly social worker, writing physician notes and filling out physician forms. I'd then have to chase down the doctor where ever they happened to to be and they would simply sign the documents without reading them.

Ever watch the film "The Devil Wears Prada"? This felt like my life. 

On top of that, if anyone on the interdisciplinary team didn't know what to, it suddenly became my job and my problem. I've had physicians ask me what specific medications to order for patients discharging home on hospice. I've had to tell physicians to write orders for generic medications because non-generics weren't covered by insurance. If a patient doesn't want to work with physical therapy because they feel tired, it's my job to fix it. If family members have medical questions and the doctor or nurse is too busy, the call is sent over to me. If a patient is frustrated because they haven't heard anything from their doctor, I have to calm them down. 

Outside of hospital staff, if a company doesn't deliver equipment on time (which seems to happen 90% of the time), it's my job to make that delivery happen. If family members are not picking up the phone, I have to do everything in my power - including calling dozens of times, leaving multiple voicemails, and calling the police if they still don't pick up - to reach them. 

When it comes to patients discharging from the hospital, so many things can go wrong. If an ambulance pick-up is late because of traffic, if a nurse didn't receive proper hand-off from the preceding shift's nurse about an impending discharge, if pharmacy lags in delivering discharge medications to the bedside, if a patient can't get certain tests done because the lab is backed up or radiology equipment is broken, if a doctor forgets to sign a form or write discharge orders, if all the nursing homes are full, if the equipment company is out of hospital beds, this all becomes my problem. It only takes one thing to go wrong for an entire discharge to fall apart. If a discharge falls apart, a patient has to stay in the hospital unnecessarily. If a patient is in the hospital unnecessary, insurance won't pay. If insurance doesn't pay, the hospital loses money, and I get blamed for it all. This makes my department, and professions as a whole, look even worse than it already does. 

Sometimes, I feel like medical social work is a group project where I do all the work, get all the blame if something goes wrong, and get zero credit when everything goes smoothly. How nice would it be to work a job that's not entirely dependent on the abilities of other people to do theirs? 

5) Monotony 

Most social workers will tell you that there's no boring day in social work. Unfortunately, this is not the case for me. My typical work day start at exactly the same time and ends at the same time (granted I get my work done). I have meetings and rounds at the same time each day. I eat lunch at the same time (or not at all). I essentially see the same types of patients every day, with variations on the degrees of complexity. In my opinion, I'm doing the same thing every day with very little mental stimulation. 

Perhaps working in an area that gives me a change of scenery (home health or CPS) might help, or maybe I'm just the type of person who'll never be happy in a traditional 9 to 5 job. What it boils down to it this: I'm bored. When I'm not bored, I'm stressed. 

6) Feeling like I'm not helping 

I went into medical social work to help people struggling in a hospital setting. Eventually, I came to the realization that my job wasn't to help people, it was to save the hospital money. Given the high patient turnover rate at inpatient hospitals, social workers don't have the luxury of time when it comes to their interventions. Providing emotional support and counseling? No, we don't have time for that. Essentially, our function is to put a band-aid on the issue and send patients their way before the hospital loses money. If I keep losing the hospital money, that's reflection of my abilities as a social worker and I end up losing my job. 

In my years in the field I've had to discharge countless homeless patients to the streets with nothing but a bus pass (because homeless shelters are full), break the news to elderly patients that they have to liquidate their assets to pay for nursing homes/care homes/caregivers, transport someone's parent to a nursing home 75 miles away (or pay thousands in hospital fees) because it's the only place with an open bed, convince an alcoholic patient to go to a sobering center knowing the place I'm sending them to is so overcrowded people sleep on the floor, and rush hospice patients home before families have even had time to process what's happening. 

Ultimately, I'm a cog contributing to what makes healthcare in this country so terrible. It's a business first, and the top priority is to make and save money. Yes, we feel sad about individual's social circumstance, but it doesn't change the fact that if we don't get them out within a specified timeframe, insurance will stop paying. 

My Social Work Values

I originally wrote this short post regarding my social work values several years ago but never published it. I'm publishing it now to remind myself that despite how burned out I feel, I am and will fundamentally always be a social worker at heart.


Sometimes, I feel so burned out by my job that I can't help but feel apathy about my patients and the social issues affecting society. During these times, I wonder if I still have the social worker mindset and belong in the social worker profession. Then, I interact with the people around me and am starkly reminded that deep down, I'm still a social worker. If you feel infuriated by any of the following, then you probably are too!

• Retelling a story about a patient and having the first response be, "That person was black, right?"  
• Being told that mental illness is "just in someone's head" and that they simply need to "snap out of it". 
• Being told that people who attempt/commit suicide are "being selfish". 
• After an exhausting day at work, being told that your job is 1) easy or 2) worthless. 
• Trying to explain the mechanics of alcohol relapse to someone, only to be told, "People who relapse are weak." 
• Being told that poor people are in that situation because they're lazy and that all safety net programs need to be eliminated completely. 
• Being told that people SHOULD be discriminated against based on sexual orientation. 
• Seeing social workers perform their job poorly, because it reflects on you and the entire profession. 
• Hearing one of the various stereotypes associated with the social work profession (i.e. "baby snatcher", "food stamp lady", "free stuff person", etc.) 
• Hearing people without BSWs or MSWs refer to themselves as "social workers". 

As emotionally exhausting and my disheartening my job can be at times, it doesn't change the fact that on a fundamental level, I still care about helping the poor, sick, mentally ill, and disenfranchised. Unless something happens to completely shake my worldview, I doubt these social work values will ever change. Even if I burn out to the point I choose to leave the profession, I know that I will always be a social worker at heart.

Inpatient vs. Outpatient Status: How It Can Bankrupt You

This post is about hospital Inpatient versus Outpatient Status, the difference between the two, and how being categorized as one over the other can result in costly medical expenses. While this content pertains mostly to individuals on Medicare, I feel everyone should know this information in the event they or a loved one are hospitalized.

Inpatient vs. Outpatient Status: How it Can Bankrupt You

One of my least favorite parts of being a hospital social worker is being the bearer of bad news. On a typical day, I'll have numerous conversations with patients telling them that their equipment, transportation, and/or post-hospital care is not covered by their insurance. Telling patients that they're liable for up to thousands of dollars in medical expenses is not exactly what I had in mind when I became a social worker.

When it comes to talking to patients about what's not covered, the most infuriating and confusing expenses often stem from whether a patient was admitted to the hospital under Inpatient or Outpatient Status.

Inpatient vs. Outpatient Status

Inpatient Status is when a patient is admitted to the hospital under a doctor's order. Typically, that order reads as follows: "Admit patient to inpatient". In addition to a doctor's order, a patient must meet insurance criteria for an inpatient admission. For Medicare patients, this boils down to the following:

• Two Midnight Rule: A physician expects a patient to stay in the hospital for more than two midnights based on medical condition.
• If staying less than two midnights, the patient requires tests and/or procedures than can only be done in an inpatient hospital setting.

Outpatient Status (also known as Observation Status) applies to those getting medical services (x-rays, emergency room care, outpatient surgeries, lab tests, etc.) but do not have a doctor's order admitting them under Inpatient Status. While emergency room patients might be moved to another part of the hospital to spend the night, they are still considered outpatient until a doctor writes an order to change them to Inpatient Status.

How Inpatient vs. Outpatient Affects Your Medical Expenses

Inpatient Status hospital stays are billed under Medicare Part A. Outpatient Status hospital stays are billed under Medicare Part B. While most Medicare patient have both Part A and B, those who have opted out of either will be responsible for uncovered expenses. 

Whether someone is Inpatient or Outpatient Status has the most profound impact on individuals needing to go to a Skilled Nursing Facility (abbreviated SNF and pronounced "sniff" by medical workers) for short-term rehabilitation. In order to be eligible for SNF, a patient must a qualifying hospital stay. A qualifying stay entails 3 Inpatient Status days in the past 30 days.

What Can Go Wrong

The difference between Inpatient and Outpatient Status can be confusing, even for physicians who deal with this sort of situation on a daily basis. Here are a few examples of what can go wrong:

• A patient is incorrectly admitted under Inpatient Status. This usually occurs with patients hospitalized for non-medical social reasons such as homelessness or lack of caregiver support at home.
• When a patient is changed from Inpatient Status to Outpatient Status, it is known as Condition Code 44. When this occurs, the entire hospital stay is billed to Medicare as Outpatient Status.
• A patient is told verbally by a physician that they are being admitted under Inpatient Status. However, the physician neglects to put an Inpatient Status order in writing, and the patient is actually just moved to another part of the hospital to be monitored under Outpatient/Observation Status.
• A patient is admitted under Inpatient Status, but is medically stable enough to transfer to SNF after only two days (therefore not meeting the 3 day qualifying hospital stay requirement).

As stated above, this has the most adverse affect on individuals needing to go to a SNF. It does not matter what a doctor, nurse, physical therapist, or occupational therapist says. Without a qualifying hospital stay of 3 Inpatient Status days, Medicare will not cover a stay at a skilled nursing facility.

When calling around to various SNFs in the Bay Area, I've gotten quotes ranging from $250-$400/night for a shared room. This is for room and board only. Depending on how long a patient needs care, a SNF stay can be quite costly.

What Else Can Go Wrong?

24 hours after Inpatient Status admission, hospitals are required to give patients an "Important Message from Medicare" Letter (often referred to as the "IM Letter" by hospital staff). This letter outlines your rights as a Medicare recipient. Most importantly, the IM Letter gives you instructions on how to appeal if you feel like you are discharged from the hospital too soon.

If the hospital changes you back to Observation Status via Condition Code 44, the IM Letter no longer applies to you. Hence, you must go through different means should you wish to appeal your discharge.

How Can You Protect Yourself?

Being informed and knowing the difference between Inpatient Status and Outpatient Status is the first step in protecting yourself from unexpected medical expenses. Here are a few more tips:

• Ask questions. In the hospital, ask your attending physician whether you are being admitted under Inpatient Status or Outpatient Status. If you don't trust your physician's response, ask to speak to a Nurse Case Manager (also known as Patient Care Coordinator) or member of the Utilization Review/Case Management/Discharge Planning Department. Other hospital employees are not as well-versed in insurance criteria and might give you the wrong information.
• Bring your medication from home. Medicare Part A covers home medication received in the hospital while Medicare Part B does not. Let's say you decide you leave your routine medication at home and receive the same medication from the hospital pharmacy. In the event you are changed from Inpatient Status to Observation Status via Condition Code 44, you become financially responsible for the home medication given to you during your entire hospital stay. If you take expensive, brand name medication, the costs can be astronomical. To be safe, bring your medication from home and have your medical team give that to you instead.
• Make sure you receive a MOON Letter or IM Letter. If not, ask for one from the Utilization Review/Case Management/Discharge Planning Department.
• Medicare Outpatient Observation Notice (MOON) Letter: The main purpose of the MOON Letter is to inform patients that they are hospitalized under Observation Status. This letter is required to be given to all Observation Status patients hospitalized for 24 hours or more. Furthermore, patients must receive a MOON letter within 36 hours after Observation Status services begin. 
• Important Message from Medicare (IM) Letter: The main purpose of the IM Letter is to inform patients of their Medicare rights and provide instructions on appealing a hospital discharge. This letter must be signed by the patient and a copy must be given to them within 48 hours of Inpatient Status admission. Additionally, another copy of the IM Letter must be provided within 48 hours of discharge.
• Know who to contact for help.
• Utilization Review Department: Also known as the Case Management, Care Coordination, or Discharge Planning, this department consists of Nurse Case Managers or Nurse Patient Care Coordinators responsible for justifying hospital stays to insurance companies. Additionally, they are in charge of discharge planning tasks such as ordering equipment and arranging SNF stays. These professionals are the first line of defense when it comes to all things insurance and discharge related.
• Hospital Ombudsman: A hospital ombudsman is a neutral party responsible for handling patient grievances. Most hospitals have an ombudsman on staff.
• Medicare: For insurance related concerns, Medicare patients can contact Medicare at 1-800-MEDICARE. For patients with Medicare Advantage plans, contact the customer service number on the the back of your insurance card. Please note that when contacting Medicare, you will likely experience long hold times.
• SHIP (State Health Insurance Program): SHIPs are state sponsored programs that give free health insurance counseling to Medicare patients. They can also assist with complaints and filing appears. To find your state's SHIP program, go here: SHIP
• Medicare Beneficiary Ombudsman (MBO): The MBO functions the same way as a hospital ombudsman but is specific to Medicare patients. If contacting 1-800-MEDICARE did not help, you can ask the representative to speak to a Medicare Beneficiary Ombudsman.
• Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO): BFCC-QIOs are responsible for ensuring quality of care for all Medicare patients. They assist with appeals, grievances, and medical necessity and quality of care reviews. You can find contact information for your state's BFCC-QIO here: Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
• The Joint Commission: Also known as JCHAO, The Joint Commission is a non-profit, independent organization responsible for accrediting roughly 21,000 health organizations in the United States. JCHAO certification is extremely important, and hospitals typically try to make the best impressions possible when they visit. JCHAO has a page on their website where you can report concerns about a healthcare organization or patient safety event: Report a Patient Safety Event
• Consider Switching to a Medicare Part C Plan (also known as Medicare Advantage): Some Medicare Advantage plans waive the three nights qualifying stay requirement. However, possible trade-offs include higher deductibles, copays, and other out of pocket costs.

Inpatient vs. Outpatient Status: Conclusion

Getting hospitalized is stressful enough without having to deal with financially devastating insurance issues. Hopefully, by knowing the difference between Inpatient Status and Outpatient Status, you can know what questions to ask and better prepare yourself to respond to any complications associated with discharge planning and skilled nursing placement. Unfortunately, unless Medicare changes their policies regarding qualifying stays - or gets rid of Observation Status altogether - there will continue to be patients impacted by this seemingly benign technicality.

Hospice: 10 Things Patients and Families Need to Know

Hospice is a care philosophy that focuses on maximizing the quality of life as opposed to the quantity of life. Hospice may include services such as medication/pain management, medical care, spiritual care, and social services. 

As a medical social worker, my job is to handle all aspects of hospice discharge planning. This includes connecting patients to a hospice agency, ordering equipment, providing resources on care facilities (i.e. board and cares, assisted livings, non-medical custodial nursing homes), and arranging transportation for hospital discharge. Additionally, I provide support to patients and family members during an stressful and emotionally draining process.

What's not publicly discussed about the hospice process is the immense pressure put on hospital employees to discharge patients quickly and efficiently. Insurance companies only pay if hospitals can medically justify a patient's stay. Once a patient goes on hospice, there is no reason for that person to be in the hospital and therefore must leave as soon as possible or the insurance company stops paying. This is often a challenge, especially when trying to provide compassionate care to patients and their families.

The purpose of this blog post is to give an honest and blunt take of hospice, what it entails, what's covered, and what happens when one elects hospice care. This information may come off as insensitive, mostly because I am feeling burned out and angry that this is how our medical system treats the dying. In addition, as the messenger who has blindsided countless patients and families with bad news, I strongly feel that it's better to know now than when it's too late.

Hospice: 10 Things Patients and Families Need to Know

#1 Hospice is NOT a place, but a care philosophy.

A common misconception is that hospice is a facility where one goes to pass away. Unfortunately, standing hospice facilities are exceeding rare, with hospice care typical administered in the home, assisted living/board and care, or custodial nursing facility. As mentioned above, hospice is not a location but a care philosophy that focuses on maximizing and individual's quality of life.

#2 Medicare pays for hospice, but does NOT cover room and board at a care facility.

In order to meet Medicare criteria for hospice, an individual must have a medical diagnosis with a prognosis of 6 months or less. Yes, Medicare covers hospice care, which includes visiting medical professionals (i.e. nurses, social workers, chaplains, caregivers), certain durable medical equipment (i.e. hospital bed, oxygen), and medication. However, Medicare does not cover room and board costs at a non-medical custodial nursing home, board and care, or assisted living. The only exceptions are if you are enrolled in your state's Medicaid program or have long-term care insurance.

#3 Hospice does NOT cover a 24 hour caregiver.

Depending on the hospice agency, you might be able to get a caregiver to come out twice a week for an hour each visit. Even individuals enrolled in a state's Medicaid program will not get 24 hours of care. The only possibilities are via family support, long-term care insurance, or private pay through a caregiver agency.

I've lost track of the number of times I've had to tell patients that they have to deplete their live savings to pay for a care facility or caregiver. The other option is to stay in the hospital and go into medical bankruptcy when insurance stops paying for their stay. And I thought I went into this field to help people.

#4 Hospice patients CANNOT stay in the hospital until they pass away.

Once the hospice decision is made, every effort is made to discharge the patient from the hospital as quickly as possible. The only exception is if a patient is actively dying with a life expectancy of 1-2 days. If a patient is expected to "linger" for 1-2 weeks, they are then transferred to a medical skilled nursing home under "comfort care". Otherwise, they are discharged to home, assisted living, board and care, or a non-medical custodial nursing home under hospice care.

#5 Patients and family members have LIMITED time to make home or care facility hospice arrangements.

I typically tell my patients and family members that once the decision to go on hospice is made, they must be discharged home or to a facility in less than 24 hours. While not every social worker does this, I feel that families and patients need to have an idea of how quickly things happen. In some cases - depending on the hospital and aggressiveness of the nurse case managers/management - I'm ordered to discharge patients the same day they enter hospice care.

The logic is as follows: Hospitals are places for individuals wanting aggressive treatment for their medical conditions. By opting for hospice, a patient is deciding to forego curative treatments in place of comfort-focused treatments. Hence, there is no medical reason for a patient to remain in the hospital. If a hospital cannot justify a medical reason for a patient to remain in the hospital, Medicare and other insurance companies do not pay.

As a medical social worker, hospice patients are my top priority due to the urgent need to get them discharged. The moment I get hospice orders, I immediately reach out to family members to confirm their wishes and determine equipment needs. Depending on the hospital's expectations and hospice agency's availability, I can get equipment delivered and a patient discharged home via ambulance by the end of my work shift. The hospice agencies I work with typically see a patient the day after discharge unless there is an urgent medical need that requires a "same day open".

If a family needs to find an assisted living facility or board and care, that may buy them an extra night or two in the hospital. Any longer and case management gets sent in to inform them that unless they leave, they will be liable for all hospital charges going forward.

#6 Most doctors know very little about the hospice discharge process.

Doctors are the experts when it comes to all things medical related. It's why they go to school for so many years and get paid more than us social workers, nurses, and other allied staff.

However, one of the most common questions I receive from doctors after they order hospice is "What do you need me to do now?" At that point, it's the social worker or nurse case manager that takes over, coordinating discharge with a hospice agency, telling doctors what equipment to order, providing support to family members, finding facilities for patients who cannot go home, and arranging ambulance transport. Doctors assist by signing off on orders, talking to patients/family as needed, completing necessary discharge paperwork, and prescribing medication (though there have been instances where I've been asked "What meds do I prescribe?", to which I respond "You're the physician").

While the physicians I've worked with are generally really helpful, there are instances where they complicate hospice discharges by telling patients and family incorrect information. This may include promising patients things not covered by insurance such as certain medical equipment or caregiving services. In worst case scenarios, I've had physicians tell family member that patients could stay in the hospital when they needed to be discharged that day. This had led to heated arguments when I or the case manager where ultimately sent in to say, "Sorry, but the doctor was wrong." In the end, when it comes to hospital discharge matters, the insurance companies call the shots.

#7 You can pick your hospice agency.

Hospitals and other care facilities might try to push for certain hospice agencies. However, Medicare mandates that patients be given a choice on the matter. While most have no preference, there are a few who've had family members on hospice in the past and want the same agency.

While social workers and other hospital staff are technically not allowed to promote one agency over another, we have an idea of which ones are the most timely and responsive, which is key during the time-sensitive discharge process. Don't be afraid to ask us! The worst that happens is we tell you the required, "We're not allowed to recommend one over another" and give you brochures of our favorites. 

#8 You need to get recertified as terminally ill to continue to receive hospice services.

A patient needs to be recertified as terminally ill by a physician in order to continue receiving hospice services. Recertifications can be completed up to 15 days prior to the start of a new benefit period, but no later than two days after the start of a new benefit period. A hospice benefit period consists of two 90-day periods and an unlimited number of 60-day periods.

Sometimes, individuals do so well that they are no considered terminal. We call this "graduating from hospice". Even though a patient "graduates" from hospice, they always have the option of reenrolling should their condition deteriorate in the future. 

#9 You can disenroll from hospice at any time.

Opting for hospice care is not a lifelong commitment. As stated above, some patients actually improve and "graduate" from hospice. 

On the flipside, some patients decide that want to try aggressive treatments again and disenroll from hospice as a result. There is always an option to enroll again at a later date. 

#10 You have the right to refuse hospice care.

Hospice is widely accepted in the medical community as the humane approach when aggressive medical treatments no longer work or are causing suffering. Many of our patients disagree with this philosophy due to religious, moral, or personal beliefs. As hospital employees, we are required to respect patient/family wishes, even though we may not agree with them.

However, this does not mean we will not try to convince you otherwise. In my short career, I've had elderly late stage cancer patients who've declined hospice and opted for all life saving treatment, including CPR. The doctors would then have lengthy conversations with patients and family about prognosis daily, to no avail. I would have numerous futile "quality of life" discussions with the family, only to get sent in for more by my superiors who were frustrated at my attempts to advocate for people who are in a "state of denial" and "torturing the patient". Ultimately, after many weeks to months, these individuals would pass away, usually while receiving chest compressions in an attempt to revive them.

If you are an elderly patient with a terminal illness who wants everything done, as I social worker I will respect that and fight for your wishes. However, prepare yourself for frequent discussions from medical staff who disagree with your decision.

Final Thoughts

As a medical social worker, my job is to advocate for and support patients and family members during this painful process. However, as a hospital employee, I'm required to follow the rules and regulations set forth by management and insurance companies in order to keep my job. This may include our aggressive approach in getting hospice patients discharged as quickly as possible. While I understand the logic of a hospital not being a holding facility for people who don't need it, the social worker in me can't help but advocate for patience and compassion for people already having to grapple with the dying process.

Hopefully this post gives better insight on hospice and the discharge process. While this information is blunt, I feel that it's better that patients and family members know now rather than be blindsided in the hospital. Lately, I've had an abnormally high number of hospice cases and what's increasingly apparent is how little patients and family members know about hospice care and what's covered. 

If you remember two things from this article, it's that 1) hospice does not cover a caregiver/room and board, and 2) once the decision is made to go on hospice, every effort will be made for hospital discharge to happen in 24 hours of less. And yes, many of us working behind the scenes will feel like terrible people for causing extra stress during an already devastating time. Ultimately, like it or not, we hospital workers can only do much as the insurance companies run the show.

Pinterest Group Board for Social Work Bloggers

Recently, I learned of Pinterest Group Boards and how they allow for communities of like-minded people to share pins with one another. Given the lack of places where social workers can gather to share their blog posts, I've decided to go ahead and start a Pinterest Group Board specifically for social work bloggers: Social Work Bloggers

To be added to this group, you'll need a Pinterest account and I'll need to know your pinterest name. You can either post it here, DM it to me on twitter (@CheapMSW), or email me at cheapsocialworker@gmail.com.

There are so many talented people in our profession. My hope is for this group to grow and become a centralized place where social workers and anyone interested in social work can share and learn from each another.

Racial Profiling of Patients By Healthcare Providers

I hate having to write yet another post on discrimination against patient by healthcare providers, but I think it's important.

Recently, I was called to investigate an abuse incident. The only evidence based on chart review and talking to the staff was "the nurse heard the family member yelling at the patient". As a result, this family member was essentially banned from seeing the patient, who was confused at the time.

To avoid violating HIPAA, here is a super abridged version of what happened next:
-The family member returned to the hospital asking for the patient's location and an explanation for the ban. I received a phone call from the nurses station, claiming that the family member was on the verge of aggression.
-I was with the family member in minutes, and the person was completely appropriate with me. The family member acknowledged speaking loudly due to the patient's confused behavior and seemed apologetic. The explanation was sound, and added details not included in the nurse's report. I sent the family member home to await my call.
-I spoke to the administrative team gathered at the nurses station, who reiterated that the family member nearly became aggressive. When asked how the family member was approached, staff members stated that they were non-confrontation, but that there was also a group of them for security reasons.
-Despite no record of abuse in the patient's chart and my personal opposition, I was ordered under the guise of "due diligence" to call the local police station to request abuse history. As expected, "yelling at the patient" was not enough evidence to get information from the police.

By this point, I had noticed that the nursing and administrative staff was predominantly one ethnicity, while the family member was another. I brought this up to my boss, along with my suspicion that the family member was being racially profiled.

Later, I received a phone call from my boss telling me to call the family member to let them come back and to apologize on behalf of the hospital. The family member was gracious enough, but expressed embarrassment at being treated like a criminal.

The longer I'm in the first, the more I notice blatant discrimination against patients by healthcare workers. While I've already posted this in a previous blog post, I think it's worth reiterating the findings of a study by the Agency of Healthcare Research and Quality:

• Blacks and AI/ANs received worse care than Whites for about 40% of measures.
• Asians received worse care than Whites for about 20% of measures.
• Hispanics received worse care than non-Hispanic Whites for about 60% of core measures.
• Poor people received worse care than high-income people for about 80% of core measures.

As healthcare providers, we are mandated to provide non-biased care to all our patients. Being a member of a disenfranchised or minority group (like the staff at my hospital) does not excuse discriminatory behavior. Imagine being provided subpar care because of your race, gender, religion, illness, sexual orientation, etc. The thought makes me ill and makes me terrified to be hospitalized.

In the case of this family member, I was the last line of defense against an organization too eager to use the "abuser" label. As long as I am a social worker, I plan on advocating for my patients to ensure they get the best care possible regardless of circumstance.