See other posts in this series here.
Discharge planning? What is that? Doesn’t it start the day before I am discharged? Actually, no. It starts from the day you are admitted. You may find that surprising, but it is true. It can be difficult if there is not a definite diagnosis, but even then, they are planning for your loved one’s discharge. You should be thinking that way too, so that when they begin talking to you about the specifics of their recommendations for his discharge, you aren’t taken by surprise. They rarely bring up the discussion the day before discharge. What is included in discharge planning?
What is included in discharge planning?
From the beginning, an understanding of how many days you will probably be in the hospital is something that is being thought about and with one level of hospital care, is known. Often, the doctor/hospitalist is told how many days he has to have you out of the hospital for the diagnosis he has given you. This is certainly true is your days are running out. There is a person who deals with insurance/medicare and the approximate number of days your loved one is to be in the hospital are discussed and planned for. Depending on diagnosis changes, the number of days may be adjusted, but this will often remain the same. The hospitalist is notified and others on the healthcare team are too.
On the floor where your loved one is a patient, there is usually a discharge planner. If there are services your loved one will need, she will work with the social worker to get you set up for those services. They will talk with you beforehand, however, it is often a phone tag situation before they catch up with you. Some will come around to the room. But if you aren’t there, you won’t get to see them.
Ask friends whose opinions you respect for home health, physical therapy and other therapies if you have any suspicion your loved one will need them. Write them down in your notebook or in the app on your phone where you keep those notes so you can find the info when you need it. They tend to go down a list and refer you to the company next on their list unless you ask. But often they don’t always know the best home health people because they simply refer people and discharge them. They don’t know if the customer service was good or not.
A social worker will also be involved if there are financial issues for the loved one. She will know a lot about community resources available for your loved one to to help him get the help he needs for living. It may be financial aid, nursing care, assistance in his home for care, etc. Why is this important? Because if you are his caregiver it may help you either directly or indirectly to take some pressure off you…either financially or emotionally. Look on the social worker as someone who may be of help to you. While your loved one is in the hospital is the time when the social worker can be of optimum help to you. Make use of that help. You may be surprised.
All post-hospital care is included in this planning.
- Are you going home or do you need intermediate care before that will be possible? Sometimes some residential Rehab is needed before your loved one will be ready to go home. Before you rush to say, “Oh no, I can care for him.” Pay attention to what needs to be done for him and how helpless/weak he is. If you qualify for Rehab, it may be wise to take advantage of it. I’m not saying he will love all of it, but the time there will get him stronger and make it easier for you when he does come home. This is helpful after a stroke or long hospitalization where a patient has become extremely weak. This interim time will help him come home to you being able to do a better job doing his ADL’s (Activities of Daily Living). This will include the accommodations that are needed for him to do them. At times, he may be mad at you for the short term. But functionally, he will do better over the long term. In that case, it is better for him, isn’t it?
- Will he need home health care? Will he need a nurse to come to the house? or rehab coming to the house? The requirements still are that he must be homebound. Often, I must be homebound to be there for them to come because I need to be here to let them in and often to learn what instructions they are giving. That may not be your situation. The downside of home health rehab is that you don’t know when they are coming. You may know the day, not the time. I found it easier to go to out patient rehab because I could schedule it and be done. For awhile, we had so many appointments that I would have gone nutty sitting around the house waiting for home health. But many don’t have that luxury. It is difficult to get out and they need the nursing/nurses’ aide assistance. You will need to decide for yourself which will work best for you and your situation.
- What follow-up appointments will you need? How many doctors will you need to follow-up with after you are discharged? After a recent hospitalization, we had a few consulting doctors to follow-up with for a bit. It took a bite out of our schedule! Appointments also overlap to include rehabs of various kinds such as speech therapy, physical therapy, etc. Think through what will work best for you. As the caregiver, you need to pay attention to your convenience. You are doing much of the work and know the things that stress you. Plan in ways that don’t add to your stress. What times of day do appointments work best for you? Schedule during those times as much as possible.
There is an educational side to discharge planning
You will be learning a number of things during your loved one’s admission. You will learn more about his diagnosis.There will usually be a folder in his room with information about the patient, as well as information about things to watch out for, precautions and other general information.
Another large portion of the teaching and information will be about the medications your loved one is taking. What are they? How often does he need to take them? What are the normal side effects? What are the dangerous side effects? What drugs do they interact with?
It is a lot of helpful information that you can refer back to. That folder contains many helpful pieces of information that you will want to refer back to when you get home and can’t remember a word of what was told to you in the hospital!
Miscellaneous information included in that discharge folder…
A summary of miscellaneous information included in the discharge folder you will take home from the hospital includes:
- the above plus a schedule for taking your medications…both the old ones and any new ones that have been added.
- a list of doctors you need to follow up with and often the appointments you have with them. If you don’t have an appointment or the appointment is not one you can keep, just call and reschedule or schedule you appointment. They will have the approximate time your appointment should be scheduled for ie. 3 weeks from discharge for example. You will have the convenience of the doctor’s name, address and phone number on the page.
- a list of the companies you have medical supplies coming from and home health agencies you are scheduled with.
- any other details you need to know about your discharge will be on those pages.
I have often found that when I get home and realize I have forgotten everything I was told, I need to take a deep cleansing breath or two and just relax my body and my brain. Then go and look in that discharge folder for the information I need. If that doesn’t help and it is a day or two after discharge, call the nurses’ station where you were and see if you can find your answer there. They will probably be able to help you get the answer you need. However, my guess is that you will be able to find the answer you need in your discharge folder.
If any of you lacks wisdom, let him ask God,
who gives generously to all without reproach,
and it will be given him.
James 1:5 ESV