The Social Admission Service

courtesy jamesfischer of flickr

courtesy jamesfischer of flickr

Well, as is bound to happen in the medical blogosphere, a minor kerfuffle has erupted in response to Jesse Pines’ piece about a social admission in the WSJ last week.

In one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t we have some sort of other option for the uninsured–or the social placements altogether?

I definitely don’t want to give any ammunition to the “the uninsured get all the medical care they need” crowd, (partially because it’s simply untrue) but we all certainly admit people for primarily social–not medical–reasons. (This probably would come as a surprise to the majority of the American population, who luckily aren’t reading this blog. And thank you, our tens of readers, for keeping this such a secret.)

If you look at pretty much any disease, under “Disposition” or “Indications for Admission,” there’s always that teensy tiny little caveat of “If the patient cannot care for himself/herself,” or “Expected clinical decline upon discharge.” From the teen with PID who just won’t take the meds or follow-up to the early-demented patient without help at home, you know they’re coming in. It’s kind of like any psych diagnosis: you can be as crazy as you want to be, talking about the demons in the lightbulbs, but as long as it doesn’t affect your ability to function in your life in any way, it ain’t a disorder. The social really does matter in medicine, just like it does in psychiatry.

Probably too late to tack this on to Congress’s health care financing bill, but what the hell: I hereby propose… THE SOCIAL ADMISSION SERVICE. Dr. Centor’s right; we probably shouldn’t be spending an expensive hospital bed on patients who don’t need hospital care, but GruntDoc is right too; we can’t simply turn away people who will get lost in the system or who can’t care for themselves. So we have a social admission service. Maybe it’s a doctor, some social workers, and a case worker–some sort of “comprehensive care team” that understands there may be a few simple medical issues, but the primary issue is placement, emergency Medicaid, or some simple labs tests/imaging/procedure. Quick admit, quick dispo. Maybe they only need vital signs once a day, maybe they can eat their own food. Maybe they don’t even need to stay overnight, if they’re safe going home. We save ourselves (and our country) some money, ourselves and our colleagues some valuable time, and best, of course, help our patients out of a bad situation.

Pipe dream? Maybe. Awful, terrible idea? Certainly possible. But I’d love to hear better ones, different ones, and solutions. No one’s going to deny that our health care system is in trouble–and not just because of the uninsured, or medico-legal liability, or the aging population, or any one thing in particular–and it’s going to take creative ways to fix it. Outside the box.

Today’s hospital system is based on an acute care, acute illness model, while our patients’ diseases have become almost completely chronic. Who knows? Perhaps acknowledging that “Admit/Discharge” is a bit too binary for today’s patient is the answer that we need.

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