On the Frontlines: A Social Worker Talks About the Challenges of Hospital Discharge Planning

Meet Kristina Nicollelis and learn about a day in the life of a social worker at Edward Hospital.

Mariya Grygorenko

Director of Client Success

Hello! I’m the new director of client success at Aidin, and my role is to ensure the continued growth and success of our customers. I came to Aidin after working as a consultant and in-house at a care coordination company.

In my first few months on the job, I’ve been on a listening tour of sorts, meeting and talking to clients to learn how they use our technology platform and seeking their feedback on improvements we can make. One of our newest customers, Edward Hospital in Naperville, Ill., invited me to visit and talk to the frontline users, the case managers and social workers who perform the essential work of putting in place a plan to meet the continuing medical needs of patients after they leave the hospital. 

The hospital is part of Edward-Elmhurst Health, a three-hospital system in the western suburbs of Chicago. Edward recently earned a top 10 ranking in the U.S. News & World Reports’ annual list of best hospitals in Illinois.

One of the people I met was Kristina Nicollelis, a social worker and discharge planner in the orthopedic unit. She’s been with Edward off and on for 17 years.

My biggest takeaway from our conversation is that coordinating care for vulnerable patients is rewarding and meaningful work, but it can also be incredibly stressful. Increased caseloads, expanding responsibilities, and greater complexity of patient needs are some of the biggest challenges of the job.

Nicollelis shared a heartbreaking story of struggling to transition a Medicaid patient to a post-acute provider. Providers are reluctant to accept Medicaid patients because reimbursements are not enough to cover their expenses. The insurance-related delay was taking a toll on the patient and hospital, increasing her length of stay.

“We have to come up with creative solutions to societal problems,” Nicollelis said with a look of resignation. “What am I going to do to get this patient out of the hospital?”

I spoke to Nicollelis in the late afternoon. I wasn’t expecting it to be so quiet in her unit. She explained that the mornings are the busiest time for discharges. 

“The average length of stay in the orthopedic unit is one or two nights, so there is a lot of turnover,” she said. “It’s a very high-paced, high-stress environment, and you have to juggle a lot. We can’t move fast enough.”

Patients in her unit often need post-acute care after joint or spine surgery because they often have comorbidities that required hospitalization in the first place versus going to an outpatient surgical center.

People want to know what their options are as soon as they are admitted. Nicollelis said she sees her role as helping patients make an informed choice.

“I want you to know what your options are so you can feel confident that you’re making the choice that’s right for you,” she said.

Not too long ago, the process to find post-acute care went like this: Nicollelis would first ask the patient if they had a provider in mind. Many patients and their families hadn’t really thought about follow-up care until they were in hospital and didn’t have a preference. She had a list of community providers, but options were limited to facilities she knew or were recommended by staff or physicians. She relied on what would be considered by today’s standards rudimentary technologies to handle referrals — phone, printers and fax machines. 

There was a lot of guesswork involved. A lot of her time was spent calling providers to see if they had a bed available and could provide needed services, such as dialysis. Sometimes these calls would turn into marketing calls.  Providers wouldn’t respond to emails and phone calls in a timely fashion. It was a lot of wasted time.

Sharing patient records also was cumbersome. While the hospital had adopted electronic medical records (EMRs), many of the skilled nursing facilities and other providers had not. The fax machine was still a major part of medical communication. With some of the longer faxes, the pages would jam.

Insurance issues have become one of the biggest obstacles in care transitions. Hospitals often have to obtain permission from health insurers, known as prior authorization, for any prescriptions, medical care, and equipment that may be needed for post-acute care. These requests are time consuming and cumbersome because the processes remain all too often manual and vary widely among health plans and insurers.

Edward was looking to adopt a more coordinated, efficient patient transfer process. The COVID-19 pandemic had exacerbated the issues they were having placing patients in post-acute care, ushering in the move to Aidin’s platform.

“I need every tool to make my job easier,” she said. “One of the things I love about Edward is that it embraces innovation.”

To learn more about the benefit Aidin has brought to Edward Hospital, click here