It was a problem that seemed to have no solution. What to do with Jong-soo, an 81-year old Korean man, who had been stuck in the hospital for two months? His condition now stabilized, the staff wanted to free up the bed, and recommended to Jong-soo’s son, his only known relative, that his father be released to a Skilled Nursing Facility. But Jong-soo’s son was proving to be very uncooperative. A number of awkward confrontations with the hospital staff resulted in him refusing to come to the hospital to sign his father’s discharge papers. He then stopped all communication, and simply vanished.
At a loss, the hospital called the Partners at Home Network member, Special Service for Groups (SSG), a non-profit health and human services organization. SSG is well versed in serving clients from diverse racial and ethnic backgrounds, particularly those from Asian and Pacific Islander communities.
The Korean staff went through Jong-soo’s belongings for clues and managed to locate the name of a family friend. Sympathetic to the situation, the friend provided the SSG team with the son’s contact details. He had returned to Korea.
Over the course of several weeks, SSG staff visited Jong-soo in the hospital, and provided his son with email and telephone reports on his father’s condition.
Slowly, they built a rapport and were able to explain the options for Jong-soo’s on-going care. This helped calm his son, who was overwhelmed by the complexities of the US healthcare system. But this was not the only cause of his anxiety. The SSG team discovered that back in Korea, Jong-soo’s family was in deep trouble. His wife had been imprisoned, his son was facing a lengthy legal battle, and the family’s finances had been frozen.
In spite of the immense difficulties, SSG staff helped Jong-soo’s son to find Korean-run assisted living facilities in Los Angeles. They set up appointments and his son was able to make a brief return to the US to select a home and discharge his father from hospital.
SSG staff visited Jong-soo in his new home. It was immediately evident that he was much happier. Having contact with his family, being assisted by Korean staff, and having familiar food to eat had improved his sense of well-being immensely. A week later, he was well enough to attend a daily adult services program and socialize with new friends.
Chan Suk Jung, a psychiatric social worker and care manager with SSG who was heavily involved in the case cites Jong-soo’s story as a perfect example of the critical role played by community-based organizations in establishing a continuity of care between inpatient and outpatient settings.
“We were able to provide intensive and ongoing support, including assistance in establishing follow up care and even accompanied Jong-soo and his son to assisted living sites so that they could get a better picture of what follow up care can look like. The son was clearly overwhelmed, and his ability to communicate in English was limited. Although the hospital staff thought his English was good, so much was lost in translation due to differing cultural beliefs and values. His language seemed abrasive in English, which contributed to the confrontational situation, but much of it takes on a different meaning when spoken in his native tongue.”
“While physicians and healthcare professionals are experts at addressing the medical needs of their patients, community-based services provide vital, social and culturally-sensitive expertise. When both sides work in unison, it’s a win-win situation for everyone,” Chan concluded.
*Not patient’s real name
