If it is not stressful and harrowing enough when your loved one has to undergo a hospital stay, bringing them home presents a whole other set of challenges. Once they are stable enough to be released, the healing is usually far from over. You will need to make sure that there are supports and plans in place so they can continue on the road to recovery. They will need to be properly cared for at home in Manhattan.
What is Discharge Planning?
Discharge planning is simply making a plan for the patient after they are discharged from the hospital. However, this is often far from simple. After a hospital stay, plans upon discharge involve careful consideration of the patient’s medical issues and a plan of care for that patient’s return home. Additionally, this often includes follow-up medical care and doctor appointments that will need to be arranged as well as homecare. This entire process and critical area is called discharge planning.
Who Does the Discharge Planning?
Discharge planners are employees of the hospital, usually social workers, who arrange all the logistics. Other important players are nurses, pharmacists, patient advocates, and doctors who all provide necessary updates. The discharge planner coordinates the patient’s healthcare team and the family or responsible parties when drafting the discharge plan to be sure all concerns are addressed.
There is a lot to plan for and consider. This is especially true for patients with diminished capacities, even temporarily. Furthermore, because studies have shown these plans directly impact patient outcomes, hospitals are re-focusing efforts on standardizing this all-important area.
Importance of Discharge Planning
A discharge planner will help smooth this transition and get your loved one back home safely again. Studies have shown that the quality of the discharge planning has a direct effect on the health of the patient as they move into this next stage of care. Sadly, almost 20% of patients have an adverse event within 30 days after discharge. Studies found that many of these were the result of poor discharge planning. In fact, interventions such as medication counseling and disease education were shown to have a direct effect on hospital readmissions.
Discharge Planning Begins Upon Hospital Admission
The Agency for Healthcare Research and Quality has developed a very handy checklist to address this issue. They lay out the following guidelines for the clinical staff while the patient is still in the hospital:
- Educate the patient and family daily during the entire hospital stay.
- Explain all medications in terms of purpose, dosage, administration, and side effects on a daily basis and ask the patient to repeat what they have learned.
- Discuss the goals of the patient, family, and clinician while in the hospital and the progress each day during their hospital stay.
- Involve the patient and their family as you explain the care that needs to be done after discharge such as wound care, feeding, toileting, and rehabilitation plans.
Developing a Plan
To develop a workable and effective plan, the discharge planner must:
- Discuss plans for discharge with the patient and/or their family based on the recommendations of medical professionals treating the patient. The social worker or discharge planner may also visit several times toward the end of the hospital stay in order to ensure the discharge plan is appropriate.
- Assess the needs of the patient and make the necessary referrals. Discharge planners ensure access to any medical treatment that may be needed after returning home. Social workers arrange for in-home nursing and therapies. They also arrange for any medical equipment to be delivered to the home.
- Provide complete information to the patient and their family to assist with the care and management of the patient. Moreover, they provide contact information within the community as well as any for any state or federal resources.
- Consider whether insurance companies offer coverage and may also assist with finding alternate payment options for anything not covered.
Easing the Transition from Hospital to Home
Transitioning your loved one from the hospital to home can be a scary time. Discharge planners collaborate with the patient and their family to determine how to make the transition from the hospital to the home as smooth as possible. They deal with everything that is critical for the well-being of the patient. The plan includes arrangements for home care, nurse’s visits, follow-up lists and the like so that the patient can recover safely in the comfort of their own home.
Home Care Considerations
When the patient is discharged to go home, you must make sure that the personal care, household care, healthcare, and emotional care of the patient is taken care of. A home care worker covers all those bases. Furthermore, that care starts immediately upon discharge. Your home health aide or companion will often meet you at the hospital to help with transferring the patient during the transportation home.
Important Questions for Homecare Plan
What kind of care is needed in terms of the ADLs?
- Is personal care needed such as bathing, personal hygiene, grooming, and toileting?
- Are special treatments needed or are medication reminders enough?
- Are any household chores necessary such as laundry, cooking, and feeding the patient?
- Does the caregiving require transferring the client from the bed to the chair?
A home health aide helps with all of the above and is trained in personal care for those who cannot perform their ADLs (Activities of Daily Life) such as bathing and toileting. If a home health aide is not needed for personal care, a companion can help with all the rest. Just knowing that you have someone there for you as you recover can be so calming and therapeutic. The home health aide and companion also provide friendly conversation and companionship.
Is the home environment ready for the patient?
- Will special equipment be necessary to properly care for the patient such as a hospital bed, shower chair, or oxygen tank?
- Are there any hazards such as area rugs, steps, or stray cords around?
- Have you installed any ramps or additional lighting for patient safety?
- Will you need to put in bathroom safety equipment such as grab bars?
A discharge planner will know how to get the necessary equipment. As well, a nurse from the home care agency will be able to help. In terms of preparing a safe environment, some agencies have Certified Aging In Place Specialists (CAPS) who can map out a safety plan for your home.
What type of home care agency supplies the home care?
- Is the agency licensed by the state department of health which is necessary for long term care insurance reimbursement?
- Do they give their staff ongoing training?
- Do they have 24-hour coverage in case of an emergency?
- Is a nurse on staff if needed?
- What is the policy regarding replacing an aide if you do not like them?
Using a Home Care Agency
Having a homecare agency take care of the hiring and scheduling of in-home care services relieves a huge burden from the patient and their families. You can be sure that the homecare worker is properly vetted and compliant with all the regulations with respect to caring for the elderly and disabled.
Many factors go into choosing an agency, and you might want to check out “10 Tips for Choosing a Home Healthcare Agency”. In the end, choosing a home healthcare agency will be the one that is well-suited to your requirements and has a stellar reputation in the community. Your interactions with the staff and your general perception of the company’s operation will likely be decisive factors in your ultimate decision.
Finally, Important Information for the Day of Discharge
The discharge papers should be given to the patient, their family, and/or the responsible party and include
- Final medication list with instructions for use and playback from the patient or caregiver.
- List of follow-up appointments already made or that need to be made along with the contact information for each.
- Contact name and information of someone at the hospital or a primary care physician to contact should there be a problem following discharge.
- If necessary, homecare agency information with contact names and the contact information for the home health aide or caregiver assigned.
Do not worry that you are alone upon being discharged from the hospital. Your plan should be full of information, support, and leads should you run into any difficulty.
David York Agency Helps Patients Upon Discharge in Manhattan…and Elsewhere
Once home, a qualified compassionate caregiver from the David York Agency can provide the extra in-home assistance the patient’s needs.
For more information about David York Agency’s home health care services, contact us at 718.376.7755. A free phone consultation can help you decide what services might be best. Our aim is to provide you and your loved one with the care they need. From geriatric social work to advice on how to deal with a diagnosis, David York Agency can help.