Prepare for Your Loved One to Come Home from the Hospital

General Discharge Planning

This article discusses discharge from a hospital or rehabilitation center to home.

Before reading this article, read our general article about “How to Manage Your Loved One’s Discharge from a Hospital or Rehabilitation Center” which explains how to:

Meet your discharge planning team
Meet with the health care team to learn diagnoses and treatment plan
Understand the next level of care
Clarify insurance options and other financial plans
Choose the next care setting and providers
Attend the discharge meeting
Arrange transportation to the next level of care
Ensure a smooth transition to the next level of care

Managing a Discharge to Home

Care Options at Home

When your loved one goes home, they may have many needs that they didn’t have before - both medical and non-medical needs. Here are some possibilities:

Outpatient Medical Care and Therapy

Home-based therapy: Therapists provide services at home
Home health care
- Wound care
- Chronic disease management programs. Ask specifically if such programs exist for your loved one’s condition
- “Transition to home” programs that follow and assist patients during the first 30 days after discharge
Palliative care: For patients with chronic illness who are still receiving curative treatment; Palliative care provides relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family.
Hospice: For terminally ill patients choosing comfort measures but not curative care

Non-Medical Support Which May Now be Required

Medical equipment or home modification
Personal emergency response systems
Assistive devices: walkers, canes, wheelchairs
Personal Care: Help with activities of daily living such as bathing, dressing, eating, toileting, and transferring
Support for Instrumental activities of daily living.

Care Management

Care managers, like ours at Care is There Geriatric Care Management, organize all the different services that your loved one needs. Care managers:

Help identify needs in all areas of life
Recommend best practice solutions
Help choose service providers
Put services into place
Monitor the performance of service providers, trouble-shoot problems, and change providers when necessary
Visit your loved one frequently to identify problems and create solutions
Ensure your loved one attends follow-up medical appointments
Advocate during emergencies
Keep you informed

Daily Money Management

Daily Money Managers, like ours at Care is There, help your loved one handle financial matters:

Ensure that financial plans are developed
File insurance claims
Pay bills
Set up safe and appropriate banking arrangements
Manage mail and correspondence
Organize tax documents
Use best practices to help prevent fraud

Clarify Insurance Coverage and Other Financial Options

Determine your loved one’s insurance coverage for the services they will need

Medicare coverage for home-based services are discussed in the articles linked to above
Check your loved one’s own insurance for their specific coverage. Contact their insurance professional for guidance. If they don’t have one, consider engaging one now.
If your loved one has long term care insurance, this is a good time to review coverage and options
Some required services may not be covered by insurance. Meet with your financial planner to discuss options

Choose Your Service Providers

By law, hospitals must give patients a choice of the provider they will use for their rehabilitation, home health care, hospice, etc. Many hospitals own such services, however your loved one may benefit from using a different provider.

You can help your loved one choose a provider and work with the discharge planner and the provider to set up that referral and transition.

Things to consider when choosing a provider:

Location - proximity to your loved one’s home and their loved ones
Providers your loved one has used and is comfortable with
Providers who offer additional services that your loved one may need later
Insurance coverage

See the linked articles above for information about how to choose service providers.

Transitioning to Home

The U.S. Department of Health & Human Services Agency for Healthcare Research and Quality distinguishes five key steps to prevent problems after discharge to a home environment. These steps are described below and included on the AHRQ Be Prepared to Go Home checklist document that can be downloaded from the page linked to above.

Make sure you feel confident about what to do and not do after arriving home

How to take care of any wounds, cuts, or incisions (ask for a demonstration)
What foods or drinks to avoid? For how long?
Are there any activities that should not be done, like: driving, sex, heavy lifting, or climbing stairs? For how long?
What exercises are appropriate? When can they be started? How often should they be done?
What should be done to make the home environment safer?

Know who will provide care at home

Know whether help will be needed at home, who will provide the help, and what they need to do to get ready
Know what to do if there is no one at home to help

Know what medications have been prescribed and how they should be taken

What medicine(s) need to be taken after leaving the hospital? Are they the same as the ones taken before admission to the hospital?
What is the name of this medicine? Is this the generic or brand name?
Why should this medicine be taken?
When and how should this medicine be taken?
How much of this medicine should be taken?
What does this medicine look like?
What are potential side effects of this medicine? What problems do I need to look out for?
Will this medicine interfere with other medicines, foods, vitamins, or other herbal supplements being taken?
Where and how will this medicine be obtained?
What medicines can be taken for pain? Upset stomach? Headaches? Allergies?

Know what problems to look for and who to call if problems arise

What problems do we need to watch for when we get home? If we have problems, how do we know when we should call?
Who do we call if we have questions or problems when I get home? What is the phone number to call?
Know when follow-up appointments are and how to get there
What appointments are needed after we leave the hospital? Can the hospital help us make these appointments?
Are we waiting on results of any tests? When should we get the results?
Are there tests needed after we leave the hospital?

How Care is There can Help

If you are a long distance caregiver or already busy with career and family responsibilities, you may not be able to coordinate your loved one’s discharge. Care is There can help. We can:

Be your family’s contact with the discharge planning team
Meet with the health care team to learn diagnoses and treatment plan
Understand the care requirements at home
Clarify insurance options and other financial plans
Attend the discharge meeting on your behalf
Arrange for transportation home
Keep you informed

For discharges to home, we can also:

Make sure you and your loved one feel confident about what to do and not do after arriving home
Help determine who will provide care at home, and put service providers in place
Learn what medications have been prescribed and how they should be taken, and put appropriate medication management service providers or devices in place
Learn what problems to look for and who to call if problems arise
Know when follow-up appointments are, make arrangements for your loved one to attend, and be present to advocate on their behalf
Visit your loved one often, and address new needs as they arise
Ensure needed assistive devices and medical equipment are in place at home.
Meet your loved one at home and settle them in.

Next Steps

Can’t be with your loved one to manage their discharge from the hospital or rehabilitation center? We can help!

Contact Care is There today for a free consultation!

Central Virginia: 434.326.5323
Toll Free: 800.434.1633
Email: Info@CareisThere.com