How to Advocate within a Hospitalization with Dr. Monique Nugent

WEBVTT

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to ask Dr.

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Mia podcast.

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Today I have Dr.

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Monique Nugent with me.

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I'm very excited about the conversation with Dr.

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Nugent.

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She is a practicing hospitalist and physician leader at a large independent health system in the Boston suburbs.

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She completed both medical school and residency in internal medicine, fellow internist here at Loma Linda University Medical Center.

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And then after completing her medical training, she a master's degree in public health while a fellow at the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University.

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Dr.

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Nugent and I are going to talk about her book called Prescription for Admission today.

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So let's welcome Dr.

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Nugent.

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Thank you so much for having me and thank you so much for your audience for inviting me into their time and their space.

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Well, thank you, Dr.

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Nugent.

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I guess the first question is, what inspired you to write this book?

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I know as a hospitalist, you're working long hours and probably don't have a lot of free time on your hands.

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you know, as someone who's chosen to really focus their practice in hospitals, I've also chosen to be a part of the conversation of improving quality.

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improving safety, improving the experience.

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And I've worked on the hospital provider side, making sure that, you know, we've got order sets that are safe and staffing is good and people feel supported to do the work.

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But over time, in all the hospitals that I've worked in on both coasts, you know, what I see for the patient experience and the patient's frustrations tend to be the same issues over and over.

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So I actually sat down to write the book during the COVID epidemic.

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And I thought I was writing a book to help people navigate the hospital with COVID because suddenly we weren't allowed to have family members in the hospital.

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The amount of visitors was very limited.

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But what I found was that I was just addressing the same issues before COVID.

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It was the same stuff over and over again.

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So you actually won't find the word COVID in the book.

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because this is really a tool that's meant to help people whenever they find themselves interacting with the healthcare system and the hospital system.

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So I'm really wanting to take my knowledge and power of improving safety and experience and quality to the patients and their loved ones.

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So that was my impetus for the book.

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wonderful.

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Yeah, the hospital is a scary place for a lot of people and and it's scary as a patient, scary as a family member.

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I like that in your in your website which will link in the show notes below that you also offer some quick guides for folks who are interested in just the very brief you know common questions that kind of come up.

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Can you share some examples of what you like listeners to know?

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Some of the common questions that kind of come up over and over.

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Yeah, there's also a quick guide in the book itself.

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There's a QR code that you can scan and kind of download to your phone to keep kind of high points.

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And really those, the really high points are about knowledge, communication, and safety.

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If you can be the owner of your information, if you can set good expectations around communication with the medical team, and if you can participate with the correct people in the care team for planning for your discharge, wherever discharge takes you, those are the things that are really gonna set you up for success in hospital stay.

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do a little bit of inpatient medicine but not it's not a major part of my clinical workflow, but I always find it, you know, stressful and it's a whole new world for people who may not know what different disciplines do and then all these people come into the room.

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You know, sometimes people leave quote-unquote against medical advice, but perhaps they just weren't given clear explanations of what the hospital can and cannot do.

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And I think I really appreciate it.

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some of the tips that you oppose within even just a quick guide as to, you know, is it safe to leave the hospital or the emergency room versus staying?

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Yeah, so what we can accomplish in the hospital and what can be accomplished in outpatient settings, people really don't understand sometimes that divide.

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One of the things that I know is a point of frustration, I will get people hospitalized and they say, oh, my dad's scheduled for an MRI of his knee.

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Can we get that done while he's here for something unrelated?

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And they get kind of frustrated and like, actually, I can't.

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you know, MRI time in the hospital is very different from that that is scheduled for you as an outpatient.

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Your insurer may see it as not part of this hospital stay.

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The MRI may not be available because they're dealing with acute issues and traumas and cancers and things like that.

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Oftentimes like, oh, he was supposed to see his cardiologist.

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Can he come and see him here?

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That might not be possible, right?

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This idea that everything can be done in the hospital.

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Conversely, there's an idea that everything has to be done in the hospital.

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We can say to people, we can support you at home with IV antibiotics in the home, wound care in the home, physical therapy in the home.

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Sometimes being at home is really not only beneficial for medical needs, but it may cut down on delirium, it may cut down on falls, it may cut down on other complications that we see with elderly people when they come into the hospital.

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And so people will say like, oh, I can't leave.

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And I get it because the number one thing I want people to feel is safe, whatever their disposition is.

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But as hospital medicine grows and we are able to support people in the home more, it's an option people should really start participating and thinking about.

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And it's not just things that are maybe not acute hospital needs, but there are a lot of hospital at home programs now where they can care for people with more acute problems.

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And they have heart monitors, they'll set nurses in the home.

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They can give lots of different medications at the home.

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And those can have benefits too.

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I actually saw one, an example of a patient who was not only a little bit on the.

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older side but did not speak a language that was commonly spoken in this country and going home with her family who was able to care for her, that is a huge safety issue, a huge experience issue, right?

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That she's able to communicate her needs and get the things that she needs from the people who love her but also bring those medical professionals into her space where she's culturally more comfortable, she's eating the foods that she's used to.

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All of that, I think, when I saw that example of a hospital at home patient, I was like, that's why it works.

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And I want people to think about if you're offered different dispositions other than just the hospital, maybe have the conversation and think about how those different places may be beneficial.

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Absolutely.

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Yeah, I think home -based medical treatments are only going to increase in the future I think because most people prefer to be at home But just as you said sometimes there's a lot of anxiety about going home because the hospital is is a safe and controlled Space they know that they can get certain medications They know that you know if they need to have an imaging test it can be done Maybe not the MRI that's scheduled as an outpatient But other more urgent needs and the opposite can also be true where people don't have support at home, but they may not have a acute need that requires them to be in a hospital anymore.

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Those are oftentimes I find to be the toughest situations because we can't keep them in a hospital forever, but they also have limitations that are not well supported in the home environment.

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I want to and I appreciate you kind of writing in your book about the different names of different facilities leaving the hospital because that's a common point of confusion for our patients too.

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Like what's a SNF or skilled nursing facility?

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What's a nursing home?

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What's a rehab?

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And all of those terminologies, I think, can mean different things to different people.

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So I think that that.

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It's just an example of what I really appreciate in your book to kind of explain this hospital world and how to really advocate for yourself and for your loved ones if you happen to find yourself in the hospital.

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Yeah, I think that when you leave the hospital, people want to go home, which is totally understandable.

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And if you can go home, that's great.

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It's that time when you don't need to be in the hospital, but home might not be the safest option for you.

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And if there's something that I want to drive into people with the book and with my discussions, the safety is the key.

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everything really should be revolved around your safety.

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And if you've got a couple of stairs to get upstairs to your bedroom and you're just not strong enough yet or you are using crutches and it's not safe for you to be in the home, places where you can get that assistance while you get better and stronger are really gonna be the key about keeping you from coming back to the hospital.

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It's all about not having to come back to the hospital.

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How can we set you up for success afterwards?

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And I think emotionally in this country, anything that's not the hospital is a nursing home.

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And it's something that I hear people say a lot.

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And I totally understand that thought process.

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But there really is a whole community of post -acute, and that's post -acute means after the hospital settings, that to me, and I say in the book very clearly, not a nursing home, not a nursing home, to me are not nursing homes because the goal is to get you back.

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to a place that you want to be and that is usually home.

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Yeah, absolutely.

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I think you're an honorary geriatrician already because your book talks about my favorite topics, you know, medications, delirium, uh, you know, uh...

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disposition, working with physical therapy, occupational therapy.

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Don't try to skip those very important disciplines.

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You know, know people don't feel well in the hospital, but when you tell the PT not to come back later, they may not come back later, and then a day later you have to stay in the hospital because the PT hasn't seen you.

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Yeah.

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such a big deal that I encourage people to understand that a hospitalization is a really active process.

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A lot of things are going to go on and you've got to participate.

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If you feel like you were dragged through a hospital stay, it's likely that you were, right?

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Because oftentimes things move so quickly that people are not expecting the next thing.

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Like, oh, the physical therapist came, but I was in the middle of eating.

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I told them to come back.

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back, right?

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Probably not.

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You know, and so like, oh, I was really tired.

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I didn't want to do that test.

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What do you mean?

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I can't get it done later.

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And so participating in your hospitalization is really, really key.

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And that's why I encourage people to, you know, write down their big goals and their little goals so that they're keeping themselves motivated.

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Like, OK, the little goal was that I got up today and I walked down the hall.

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That was a little goal.

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The big goal was that I got this test and I got to talk to the neurologist.

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OK, things are moving.

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I'm participating.

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let's keep going.

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Because yeah, you're right.

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What ends up happening sometimes is that the team thinks that the conversation is happening and the patient is not aware that the conversation is happening.

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So take the PT thing like, oh, he saw PT.

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No, he said he was too tired for PT.

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Oh, he's too weak to go to PT.

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OK, that means.

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But really what it was was, oh, he said he was tired.

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He meant I will come back.

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And so you're having these two different experiences in these two different conversations.

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And then it's time for discharge.

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And it's like, OK, well, you didn't you weren't able to participate with physical therapy.

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So you didn't meet the threshold for an acute rehab.

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So we're going to talk about the skill.

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a facility.

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What are you talking about?

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I didn't meet the threshold for acute rehab.

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You never get, right?

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So this is why I really encourage people to be an active participant.

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And I know it's hard.

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You're sick.

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You're tired.

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You're in pain.

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You're doing a whole bunch of different things.

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But really try to lean in and participate as much as possible.

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Yeah, absolutely.

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And I think that gets to my next question, which is, you know, improving the communication with the inpatient team.

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It is such a big team and so many different disciplines and half the time, you know, you don't know who's who.

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Was it a doctor I just saw or was that the resident or was that the fellow?

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And what advice do you have when you feel like the inpatient team doesn't seem to be responding to your questions or your family's questions?

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I say that's the time to call for a family meeting.

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That's the time to get all the stakeholders together.

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Who is a stakeholder?

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A stakeholder is whoever is part of the decision making process, right?

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So it may be that the patient is making their own decisions, but no decision is made in a vacuum.

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You know, the patient's sister also helps them navigate their healthcare.

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And so the patient's sister is part, or if the sister is the decision maker, she's not the only one making the decision.

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Her husband is also helping her figure things out and how does everything fit into their life.

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So he's a statement, right?

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So who's ever part of the decision making process and the critical parts of the care team.

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You're probably unlikely to get every specialist every day.

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Talking to therapists, people will say, oh, the physical therapist never called my daughter.

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Physical therapists, occupational therapists, they're unlikely to be able to call and have that bandwidth unless something is going on.

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They're just not really reaching out to families on that regular basis.

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But your hospitalist is the person who is supposed to be coordinating this care.

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They're supposed to be in touch with all the different.

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specialists, the speech therapist goes back to them, the orders go back to them, the medication list, all of that.

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And so bringing them and if somebody else can attend, at that site nurse is great to tell you what the moment to moment experiences in your inspiration were, right?

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But whatever can be brought together for the critical parts of that team.

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And now we're going to sit down and we're going to have productive conversation.

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And you alluded to it on my website, I have a download for people on.

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how to shape and plan for a family meeting, what, when, where, and why of a family meeting.

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And a good family meeting should end with decisions about moving forward with the care, goals of care, and a discussion, if not a decision about disposition, right?

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So it should be like, okay, what are our next steps?

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Our next steps is X, Y, and Z with the cardiologist, and we're gonna continue antibiotics.

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What are our goals of care?

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What are we trying to achieve?

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Well, maybe mom can't go home, but...

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can she go to a rehab or like we totally realize that mom cannot live alone by herself anymore.

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So we're gonna need some more time to get our resources for some longer term care.

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Okay, what does that mean?

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Can we get her into a skilled nursing facility?

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Can we get her into a short term rehab while we get our resources together, whatever it is.

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So those are really the things that should be accomplished at the end of a good family meeting.

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Absolutely.

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I think having the patient and family goal in the forefront of our minds is really important.

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And sometimes I know as a healthcare profession, we don't explicitly ask, like, what are your goals?

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And this is where I think patients and families can be empowered to say, like, my goal is to be able to go home and home has, you know, five steps to get in.

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So, oh, that means PT can now work with you to see if you can go up five steps.

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Those are kind of crucial details that may seem like it's not that important when there's more major medical diagnostic tests to do, but really make a big difference in terms of where people go.

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The other thing that I oftentimes hear from patients is that they're unhappy about the type of rehab they're being slotted to go to.

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And I...

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Unfortunately, I tell folks that the type of rehab or exactly where it go is a mix of factors.

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Some of it is outside of all of our control because it depends on what insurance you have and the approval of the insurance and which facilities have a bed available.

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But I think that's oftentimes another point of negotiation is to like, where is the best safe place even if that may not be.

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ideal place.

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I don't know if you have any other suggestions or tips about this very important transition.

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Yeah, you bring up a really good point.

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People's choice about where they go for rehab often is a mix of prior experiences, desires for what they're trying to accomplish, physical location, right?

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They may want to be in the neighborhood of family and friends who can come to visit them.

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But then where they're able to go is a mix of where their insurer has a contract, what the facility can accomplish for you, and then does the facility have a bed.

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So it is really hard to match those two sometimes to get the one that people are really happy with.

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What I always suggest to people is if this is kind of your first time doing the post-acute care thing.

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if you have someone who can go on the outside and go and visit these places and just kind of see like is it really what it looks like on the website and the brochure probably not 100 % but there may be things that you really like about it that when you show up you didn't know were there or things that are just kind of like oh this is a no -go right.

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Because the last thing you want, and it happens a ton, is for people to go to the facility and then be like, I'm not getting off this stretcher.

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No thank you for me back to the hospital.

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Which happens.

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It happens more than you think.

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And it happens for tons of reasons.

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And it really often is that no one has laid eyes on the facility to really know what's happening and what they're going into.

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And also go with the idea that I'm here to accomplish something.

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Right?

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really go empowered to participate and accomplish what you're set out to do.

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I'm here to accomplish getting back.

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to my long -term care facility.

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I'm here to accomplish getting back home to my cats and my grandkids, whatever it is.

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And that way you're still looking for that goalpost.

00:20:06.134 --> 00:20:10.554
You're still doing your big goals and your little goals, and you're still participating and driving forward.

00:20:10.554 --> 00:20:18.314
And if you really see it as this is a temporary thing, you know, hospitalizations and post -future care settings can be kind of isolating.

00:20:18.314 --> 00:20:28.528
So if you see it as I'm going to work to get through this to the next thing that I want, you're, you know, you're not hopefully getting into this like, oh my goodness, I'm still doing this type of feeling.

00:20:29.133 --> 00:20:29.982
Exactly.

00:20:29.982 --> 00:20:37.952
And I think the post -acute environment, whether it's a rehab or not, is also another place where people can act.

00:20:37.952 --> 00:20:48.482
for themselves for a family meeting if things don't seem to be going well or you feel like you haven't talked to the right specialty or the doctors there.

00:20:48.482 --> 00:20:52.403
It is also important to kind of gather everyone together.

00:20:52.403 --> 00:21:00.623
There are very similar roles kind of in these skilled nursing facilities, rehabs, as it is in the inpatient setting.

00:21:00.623 --> 00:21:07.623
Oftentimes there's a social worker or case manager who is helping transition people out of those facilities back home.

00:21:07.722 --> 00:21:09.497
So, So I think what Dr.

00:21:09.497 --> 00:21:15.153
Nugent has mentioned in the book can also be relevant even beyond the hospitalization.

00:21:15.153 --> 00:21:19.064
Yeah, no, those professionals are, like you said, they're key.

00:21:19.064 --> 00:21:24.453
They're key to getting you what you need in the community to be successful.

00:21:25.173 --> 00:21:31.173
There are oftentimes a conversation between the case manager of the hospital and the case manager in the facility has already happened.

00:21:31.173 --> 00:21:37.582
And they know what your goals are, but still plug in with them and make sure that everything is moving in the right way.

00:21:38.371 --> 00:21:39.090
Yeah.

00:21:39.090 --> 00:21:41.641
And lastly, I think Dr.

00:21:41.641 --> 00:21:52.530
Nguyen has shared one of her good friends' mental health corners throughout the book, because this is a highly anxiety provoking type of conversation.

00:21:52.530 --> 00:22:01.194
I think just in talking about it, you may already be thinking about experiences of hospitalizations that either you or your family members have been through.

00:22:01.194 --> 00:22:03.694
may be good or may be bad.

00:22:03.855 --> 00:22:05.664
And I was hoping that Dr.

00:22:05.664 --> 00:22:20.625
Nugent can kind of lead us through one of these exercises just to calm ourselves down so that we can, you know, obviously use them in a moment of crisis, but maybe also helpful in our everyday life when whenever things get stressful.

00:22:20.625 --> 00:22:21.925
Yeah, so Dr.

00:22:21.925 --> 00:22:33.645
Nyota Pia is a great friend of mine, went to college together, and she is a very talented psychiatrist, works a lot in the inpatient setting, and she did a great job contributing some mental health tips.

00:22:33.645 --> 00:22:37.246
So one of my favorites that she included is square breathing.

00:22:37.685 --> 00:22:41.809
And what this is, it's a practice of controlling your breath.

00:22:41.809 --> 00:22:43.289
to help with anxiety.

00:22:43.289 --> 00:22:51.069
And it's something that I often tell patients to try and practice, and I do with the bedside, even before she had put it in the book.

00:22:51.130 --> 00:22:52.869
Because you know what?

00:22:52.950 --> 00:22:56.009
When people say I'm nervous in the hospital, I get it, right?

00:22:56.009 --> 00:22:58.210
There's lots of reasons to be nervous.

00:22:58.210 --> 00:23:01.849
I never once tell people, like, no, you shouldn't be nervous.

00:23:01.849 --> 00:23:04.430
It's like, oh, you got a new diagnosis.

00:23:04.430 --> 00:23:06.930
Oh, you're experiencing a flare of something.

00:23:06.930 --> 00:23:08.903
That's anxiety provoking.

00:23:09.105 --> 00:23:13.130
So what we're going to do with square breathing is...

00:23:29.634 --> 00:23:30.481
trees.

00:23:30.481 --> 00:23:33.001
No, you muted.

00:23:33.461 --> 00:23:34.902
Yeah, awesome.

00:23:35.221 --> 00:23:43.337
What we're going to do with square breathing is out in for five, out for five, in for five.

00:23:45.266 --> 00:23:49.885
And if we can do this together, I will count, otherwise I'm sorry.

00:23:51.726 --> 00:23:54.445
And everyone else take a deep breath in, okay?

00:23:54.445 --> 00:23:56.105
And we'll close our eyes.

00:23:56.105 --> 00:23:58.347
And we're gonna take a deep breath in.

00:24:00.049 --> 00:24:05.930
Two, three, four, five, out.

00:24:06.170 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:07.829
Two, three, four, five, out.

00:24:07.829 --> 00:24:11.173
Two, three, Five.

00:24:11.413 --> 00:24:12.634
In.

00:24:12.933 --> 00:24:13.913
Two.

00:24:14.074 --> 00:24:15.193
Three.

00:24:15.193 --> 00:24:16.314
Four.

00:24:16.453 --> 00:24:17.534
Five.

00:24:17.534 --> 00:24:18.634
Out.

00:24:18.814 --> 00:24:19.662
Two.

00:24:26.097 --> 00:24:33.198
The breath is a really great way of controlling your autonomic nervous system, which is a nervous system that goes on its own.

00:24:33.678 --> 00:24:36.453
And the breath is a great way to control that.

00:24:37.250 --> 00:24:38.161
Thank you so much.

00:24:38.161 --> 00:24:40.221
Yeah, that's really great and easy to do.

00:24:40.221 --> 00:24:44.411
You can do it whenever, even if you're driving, just don't close your eyes.

00:24:45.122 --> 00:24:46.622
that's a good point.

00:24:47.138 --> 00:24:52.409
If you're listening to this episode while you're driving, please don't close your eyes, but you can still practice the square breathing.

00:24:52.409 --> 00:24:58.798
Breathe in for five, breathe out for five, breathe in for five, breathe out for five.

00:24:59.078 --> 00:25:10.398
And I think once we focus on our breathing, I feel like I'm already feeling slightly less anxious about some other things unrelated to today's topic.

00:25:10.419 --> 00:25:11.888
Well, thank you so much, Dr.

00:25:11.888 --> 00:25:14.298
Nguyen, for all of these great tips.

00:25:14.298 --> 00:25:17.444
Folks, feel free to check out her book.

00:25:17.444 --> 00:25:25.634
can get it on Amazon as well as other places either online or physically and also check out Dr.

00:25:25.634 --> 00:25:33.365
Nugent's website which is moniquenugent.com Dr.

00:25:33.365 --> 00:25:36.884
Moniquenugent .com, sorry about that.

00:25:37.505 --> 00:25:43.904
And this is where you can get the helpful tips in terms of the quick guides.

00:25:44.002 --> 00:25:45.133
Thank you again Dr.

00:25:45.133 --> 00:25:45.462
Nugent.

00:25:45.462 --> 00:25:47.560
Anything else you want to add?

00:25:47.602 --> 00:25:50.961
I thank you guys for sharing your time with me.

00:25:50.961 --> 00:25:53.741
Please realize that this is a tool.

00:25:53.741 --> 00:25:57.521
I have paid places for people to write down their thoughts on.

00:25:57.521 --> 00:26:03.122
code status and different, you know, CPR, places for you to write down and practice your medications.

00:26:03.122 --> 00:26:10.051
I've created this book to be used, to be dog -eared, to be rolled up and put in a bag when you're running to the hospital to see mom, right?

00:26:10.051 --> 00:26:12.801
So please dig in, use this.

00:26:12.801 --> 00:26:14.362
There's lots of really great tools.

00:26:14.362 --> 00:26:15.122
And again, Dr.

00:26:15.122 --> 00:26:18.321
Mia, thank you so much for sharing your time with me.

00:26:18.467 --> 00:26:19.446
Thank you.

00:26:19.446 --> 00:26:20.807
See you all next time.

00:26:20.807 --> 00:26:31.646
And if you enjoyed this episode, please share it with a friend or a family member and leave me a review on Apple Podcasts or wherever you listen to this podcast.

00:26:31.646 --> 00:26:34.267
Thank you so much and talk to you next time.