Discharge Planning

Who is in Charge upon Discharge?

Routines are nice because you generally know what to expect; however, if you’ve ever been unexpectedly hospitalized, life can quickly become anything but routine. Upon being discharged, people often find themselves facing a world of uncertainty. In an attempt to reduce medical costs, the federal government has placed increased emphasis on care transitions, a process that can quickly overwhelm many patients and their families.

The goal of care transitions is to achieve a continuity of care whereby patients, with the help of family and community support, successfully move from one setting to another with the information, skills and support needed to manage the ongoing care process.

One measurable aspect of success specific to the Affordable Care Act (i.e., ObamaCare), is a reduction of hospital readmissions within 30 days of discharge.

Discharge is often an overwhelming experience as patients and their families suddenly become responsible for all aspects of their care, which days earlier in the hospital had been facilitated by a team of trained and experienced healthcare professionals.

Patients and family members are often inundated with information, and discharge instructions can be confusing. Barriers and breakdowns in communication are common to care transitions, especially for people with multiple health issues, lower literacy and advanced age. Additionally, transitions typically involve new roles, responsibilities and relationships that may present challenges.

Based on our experience and expertise in providing recuperative care to those recovering from surgery, illness or injury, we share five suggestions to help patients and families successfully transfer from the hospital to home.

  1. Anticipate Care Needs – With any health condition, there are different roads to recovery that people are likely to take. Meet with your healthcare team before discharge to discuss your specific situation and ask questions to get an idea of what you and your family might expect over the next 30 to 60 days (e.g., medication regimens, medical needs, therapy, need to monitor vital signs/blood sugar, activity and diet restrictions, help with transfers and transportation). Additionally, make sure you are clear about roles and responsibilities.
  2. Request Education – Take time to learn from your healthcare team about your condition and care needs. Don’t expect yourself to remember everything the first time through. What may seem clear and simple now may seem vague and complex later. In addition to information gathered during conversations, ask for written education materials you can read and refer to over time. Also, to help ensure understanding, take time to paraphrase information, clarify your understanding and demonstrate how to do things.
  3. Focus on Safety – It is important for patients and family members to have a clear understanding of discharge instructions. Make sure you know what is needed and that you are equipped and able to do what is necessary (e.g., medication management, disease self-management, arranging follow-up appointments, helping with personal care and activities of daily living). Also, become familiar with signs and symptoms that might suggest a need for immediate follow-up or a call to 911.
  4. Clarify Assumptions – The discharge process is often fraught with assumptions. For example, when you call your primary care physician (PCP) to make an appointment in three days, the next one available might not be for another three weeks. Or, you assume family members will be able to clear their schedules to provide the care and support you need 24/7. Ask questions, such as, “What if I cannot get in to see my PCP within the time frame indicated?” and “Is the hospital sending my medical records to my PCP and if he/she does not have them at the time of my appointment what should I do?”
  5. Seek Support – The time and effort required to deliver the needed level of care and support can be daunting. Home care providers such as Home Helpers can be an important part of the care team. At Home Helpers, we recognize the care demands are often more than family can handle alone while still meeting other responsibilities. We tailor our services to meet our clients’ needs. A free consultation can be arranged to take place at a hospital before discharge to arrange for home care services and to help ensure a care transition goes smoothly.

As your partner in the care process, Home Helpers structures its services around the needs, goals, preferences, and values of those we serve. We consider it a privilege to assist in care transitions and provide home care services needed to make life easier.