One of the most creative discharge plans that I have ever been associated with involved the repatriation. Repatriation is "the act of sending or bringing someone, or sometimes money or other property, back to the country that he, she, or it came from" (Cambridge University Press, 2023, p. 1) of a World War II (WWII) Royal Air Force (RAF) Pilot from South Florida to London, England. The elderly gentleman presented to the emergency department after suffering a stroke with resulting cognitive deficits. This individual had been a long-term resident in the Caribbean and also had a small condominium in South Florida that he used on rare occasions; he was not an American citizen. Given the patient's lack of U.S. citizenship and therefore his lack of ability to qualify for any long-term care and services benefits in the United States, his discharge options appeared bleak, but his needs immanent.
The patient's son was listed as next of kin and he was able to provide some background information, so that we could best serve his father and was initially helpful in working toward a discharge plan. As the patient was stabilizing and his future care needs became clearer, his son advised us that he would not assume any role, nor accept any responsibility for his father's future care. Without judgment, we moved forward. It was clear that the patient would need long-term custodial placement to meet his short- and long-term needs and to ensure safe and quality care.
Given the patient's status as a former Royal Air Force (RAF) World War II (WWII) Pilot, a conversation was initiated with the British consulate general's office in Miami. They advised us that this individual was a British subject in good standing, and given his veteran's status, he was eligible for placement in a care home. British care homes, sometimes referred to as residential homes, provide accommodation and personal care for people who need extra support in their daily lives. Personal care might include help with eating, washing, dressing, going to the toilet, or taking medication. Some care homes also offer social activities such as day trips or outings (AGE UK, 2022).
The British consulate general's office assisted us in initiating the process needed for care home placement. This involved working with the British agency tasked with locating a care home bed and providing the associated and required clinical documentation regarding this gentleman to secure his placement. We were advised that once the patient arrived at Heathrow Airport in London, he would need to be taken to a specific agency at the airport where we would be given the forms needed to accompany the patient to a specific accident & emergency (A&E) department at a local hospital.
With the assistance of legal counsel, the guardianship process was initiated. During this time it was discovered that the son had the patient sign a Quit Claim Deed. This immediately provided the patient's son to quickly transfer ownership of the father's property to him (one of the quickest and cleanest ways to transfer property), leaving the patient with no financial means. This questionable act, by the patient's son, led to allegations of fraud and a fraud hearing before a judge. At the hearing, the judge was made aware of the facts, along with the impending need to complete the process to expatriate the patient back to the United Kingdom for placement in long-term care. The directive from the judge was to have me escort the patient back to the United Kingdom to ensure that travel and placement in the care home went smoothly and the patient was provided with appropriate care throughout the process, including his travel.
In preparation for the trip, we reviewed the patient's physical needs, and a male certified nursing assistant (CNA) was identified to assist in the transport of the patient. Three tickets were booked on a night flight to the United Kingdom; medical records and other required documents were obtained and copied and accompanied the patient, along with his clothes, medications, and other personal needs. The flight was uneventful, British immigration authorities processed us quickly and efficiently, all the required care home placement forms were obtained once the patient was presented at the airport office, and the ride to the A&E department was smooth. Upon arrival at the A&E department, the patient was swiftly attended to.
Lessons learned:
* Not all family members have the patient's best interests at heart. Always consider the possibilities of neglect, fraud, and abuse, including financial abuse.
* Consult legal counsel when potential fraud is suspected or when considering repatriation or other major life changes to ensure that everything is done within legal parameters and in the patient's best interests.
* Know your responsibilities and comply with elder (and other) abuse-reporting requirements.
* Reach out to embassies and consulates for guidance as to available resources for their citizens and assistance in repatriation.
* Clinical documentation and discharge planning documentation must be detailed and frequent.
* Complete medical records, legal documents (such as wills, powers of attorney, and advance directives for health care [living will]) should accompany the patient throughout their interactions with case management and the health care system.
References