Your loved one is getting discharged from the hospital, so what is next?
This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one. If you are a caregiver, you play an essential role in this discharge process: you are the advocate for the patient and for yourself.
Discharge planning is “a process used to decide what a patient needs for a smooth move from one level of care to another.” In general, the basics of a discharge plan are:
The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation and chores; and possibly referral to home care services.
Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, decrease healthcare costs, and adequately prepare you to take over your loved oneʼs care.
Not all hospitals are successful in this. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release.
Even simple measures help immensely. For example, you should have a telephone number(s) accessible 24 hours a day, including weekends, for care information. A follow-up appointment to see the doctor should be arranged before your loved one leaves the hospital. Since errors with medications are frequent and potentially dangerous, a thorough review of all medications should be an essential part of discharge planning.
The discharge staff will not be familiar with all aspects of your relativeʼs situation. As caregiver, you are the “expert” in your loved oneʼs history. While you may not be a medical expert, if youʼve been a caregiver for a long time, you certainly know a lot about the patient and about your own abilities to provide care and a safe home setting.
The discharge planners should discuss with you your willingness and ability to provide care. You may have physical, financial, or other limitations that affect your caregiving capabilities. You may have other obligations such as a job or childcare that impact the time you have available. It is extremely important to tell hospital discharge staff about those limitations.
Some of the care your loved one needs might be quite complicated. It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator, or transferring someone from bed to chair.
If your loved one has memory problems caused by Alzheimerʼs disease, stroke, or another disorder, discharge planning becomes more complicated, and you will need to be a part of all discharge discussions. You may need to remind the staff about special care and communication techniques needed by your loved one. Even without impaired memory, older people often have hearing or vision problems or are disoriented when they are in the hospital, so that these conversations are difficult to comprehend. They need your help.
We suggest you keep the questions summarized below (on pages 5–6 of the printout) with you, and request that the discharge planner take the time to review them with you.
Listed below are common care responsibilities you may be handling for your family member after he or she returns home:
Community organizations can help with services such as transportation, meals, support groups, counseling, and possibly a break from your care responsibilities to allow you to rest and take care of yourself.
If you need to hire paid in-home help, you have some decisions to make. Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. You might be handed a list of agencies, with instructions to decide which to use—but often without further information. This is another good reason discharge planning should start early—as caregiver, youʼll have time to research your options while your loved one is cared for in the hospital.
Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background.
You have a choice between hiring an individual directly or going through a home care or home health care agency. Part of that decision may be affected by whether the help will be “medically necessary” i.e., prescribed by the doctor, and therefore paid for by insurance. In that case, they will most likely determine the agency you use. In making your decisions, consider the following: home care agencies take care of all the paperwork for taxes and salary, substitutes will be available if the worker is sick, and you may have access to a broader range of skills. On the other hand, there may be a more personal relationship if you hire an individual directly, and the cost is likely to be lower. In either case, try to get recommendations for hiring from acquaintances, nurses, social workers, and others familiar with your situation. TenderCare Services can help your loved one once they are discharged from the hospital and need post-surgery care.
You might not be aware that insurance does not pay for all services after a patient has been discharged from the hospital. However, if something is determined by the doctor to be “medically necessary,” you may be able to get coverage for certain skilled care or equipment. You will need to check directly with the hospital or your insurer to find out what might be covered and what you will have to pay for. Keep careful records of your conversations.
If you donʼt agree that your loved one is ready for discharge, you have the right to appeal the decision. Your first step is to talk with the physician and discharge planner and express your reservations. If that isnʼt enough, you will need to contact your insurance company.
Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. Several pilot programs have illustrated those benefits, but until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. Caregivers, patients, and advocates are continuing their efforts to alter our healthcare system to make discharge planning a priority. With our graying population, these changes are ever more necessary.