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.

What Is Discharge Planning?

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:

• Evaluation of the patient by qualified personnel
• Discussion with the patient or his representative
• Planning for homecoming or transfer to another care facility
• Determining whether caregiver training or other support is needed
• Referrals to a home care agency and/or appropriate support organizations in the community
• Arranging for follow-up appointments or tests

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.

Why Is Good Discharge Planning So Important?

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 Caregiver’s Role in the Discharge Process

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.

Getting Help at Home

Listed below are common care responsibilities you may be handling for your family member after he or she returns home:

• Personal care: bathing, eating, dressing, toileting
• Household care: cooking, cleaning, laundry, shopping
• Healthcare: medication management, physicianʼs appointments, physical therapy, wound treatment, injections, medical equipment and techniques
• Emotional care: companionship, meaningful activities, conversation.

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. Big Hearts Homecare can help your loved one once they are discharged from the hospital and need post-surgery care.

Paying for Care After Discharge

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.

What if You Feel It’s Too Early for Discharge?

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.

Conclusion

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.

Some Basic Questions for Caregivers to Ask

Questions about the illness:

• What is it and what can I expect?
• What should I watch out for?
• Will we get home care and will a nurse or therapist come to our home to work with my relative? Who pays for this service?
• How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments?
• Have I been given information either verbally or in writing that I understand and can refer to?
• Do we need special instructions because my relative has Alzheimerʼs or memory loss?

What kind of care is needed?

• Bathing
• Dressing
• Eating (are there diet restrictions, e.g., soft foods only? Certain foods not allowed?)
• Personal hygiene
• Grooming
• Toileting
• Transfer (moving from bed to chair)
• Mobility (includes walking)
• Medications
• Managing symptoms (e.g., pain or nausea)
• Special equipment
• Coordinating the patientʼs medical care
• Transportation
• Household chores
• Taking care of finances

Questions when my relative is being discharged to the home:

• Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment?
• Are there stairs?
• Will we need a ramp, handrails, grab bars?
• Are hazards such as area rugs and electric cords out of the way?
• Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment?
• Who pays for these items?
• Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?
• Will insurance pay for these?
• Do I need to hire additional help?

Questions about training:

• Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment?
• Have I been trained in transfer skills and preventing falls?
• Do I know how to turn someone in bed so he or she doesnʼt get bedsores?
• Who will train me?
• When will they train me?
• Can I begin the training in the hospital?

Questions when discharge is to a rehab facility or nursing home:

• How long is my relative expected to remain in the facility?
• Who will select the facility?
• Is the facility clean, well kept, quiet, a comfortable temperature?
• Does the facility have experience working with families of my culture/language?
• Does the staff speak our language?
• Is the food culturally appropriate?
• Is the building safe (smoke detectors, sprinkler system, marked exits)?
• Is the location convenient? Do I have transportation to get there?

For longer stays:

• How many staff are on duty at any given time?
• What is the staff turnover rate?
• Is there a social worker?
• Do residents have safe access to the outdoors?
• Are there special facilities/programs for dementia patients?
• Are there means for families to interact with staff?
• Is the staff welcoming to families?

Questions about medications:

• Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken?
• How will we know that the medicine is effective?
• Will this medicine interact with other medications? prescription and nonprescription? or herbal preparations that my relative is taking now?
• Should this medicine be taken with food? Are there any foods or beverages to avoid?
• Can this medicine be chewed, crushed, dissolved, or mixed with other medicines?
• What possible problems might I experience with the medicine? At what point should I report these problems?
• Will the insurance program pay for this medicine? Is there a less expensive alternative?
• Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling?

Questions about follow-up care:

• What health professionals will my family member need to see?
• Have these appointments been made? If not, whom should I call to make these appointments?
• Where will the appointment be? In an office, at home, somewhere else?
• What transportation arrangements need to be made?
• How will our regular doctor learn what happened in the hospital or rehab facility?
• Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?

Questions about finding help in the community:

• What agencies are available to help me with transportation or meals?
• What is adult day care and how do I find out about it?
• What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services?
• Where do I start to look for such care?

Questions about my needs as a caregiver:

• Will someone come to my home to do an assessment to see if we need home modifications?
• What services will help me care for myself?
• Does my family member require help at night and if so, how will I get enough sleep?
• Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper?
• What medical conditions and limitations do I have that make providing this care difficult?
• Where can I find counseling and support groups?
• How can I get a leave from my job to provide care?
• How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs?

* Adapted from the Family Caregiver Alliance website