A very important step when Transitioning from Hospital to Home is to not be afraid to advocate for your loved one.
A discharge planner can help you with the uncertainty and worry surrounding your loved ones discharge. Every hospital has a discharge planner and it is their job to coordinate all the resources necessary to get the patient out of the hospital as soon as possible. When working with a discharge planner you must remain a strong advocate for your loved one. A discharge planner must work in the best interests of the hospital, as well as your loved one. Hospitals want patients discharged at the earliest time possible. Insurance restricts length of stay. As a result, discharge planners have to consider what is cost-effective for the hospital while also considering the family’s wishes for discharge and the wellbeing of the patient. As a caregiver, you play an important role in the discharge process. You know your loved one’s history and cognitive abilities. You know the home situation and whether it is suitable for recovery. Make sure that you are heard and play an active role in the discharge plan so that it is appropriate. You want a plan that will encourage, rather than deter your loved one’s successful recovery. Unfortunately, patients are released from the hospital much faster than in the past. That means that they may still be frail and their health condition tenuous. You need to have a full understanding of exactly what post-hospital care is required. Each patient has different post-hospital needs. A cancer patient needs much different care than a stroke patient. Pain, nutrition, personal hygiene, and fall prevention all have to be a focus of concern at home Be painfully honest with the discharge planner about your loved one’s home situation. If there are in-home care gaps because you have to work or pick up children, tell the planner. It is their job to help plan for those gaps and find services to fill them. If you know that your loved one will not or cannot follow medication instructions tell the planner that too. The more they know about what is likely to happen at home, the more they can support your loved one’s needs. In general, a discharge plan will include:
An evaluation of the patient by clinicians and assessment of their current health status.
Discussion and planning for discharge to home or rehabilitation.
Resourcing at home support if needed and providing information on referrals to home care agencies.
Ensuring discharge instructions are understood.
As a caregiver, you should receive the following information:
Detailed discharge instructions including care that is specific to your loved one’s condition.
Doctor’s notes on prognosis including whether your loved one’s condition is likely to improve and things to watch for that would indicate a worsening of the condition.
Level of approved activities inside and outside the home.
Appropriate and suggested dietary restrictions.
Detailed information on medications; dose, frequency, potential side effects. Ask specifically if the new medications have been cross-referenced with pre-hospital medications so that there will not be any dangerous contraindications.
Suggested supportive equipment including wheelchair, walker, cane etc.
Referral to home care services.
24/7 access to the discharge planner with phone number, e-mail etc. Ask about the process on the other end of the line when you call.
The time after hospital discharge can be very tenuous for an older person’s health. You can educate yourself about this and the questions you should ask of a discharge planner in this detailed guide. You know your loved one best. Don’t be afraid to advocate for them.
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