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
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