SCO Blog April 2016 “My dad is in the hospital. He is being discharged this week. What do I need to do to make it successful?” Emily from Midtown

Discharge discussions and planning from a hospital should start at admission. I am hopeful that you have connected with both his hospital case manager and his charge nurse. If not, this is very important to do quickly. The combination of these two individuals or roles will be vital in ensuring that dad has what is needed upon discharge.

Hospitals are intended for the short-stay crisis management of presenting health changes. The stay is and should be hyper-focused on the current concerns in question and in finding immediate solutions to return the person to their previous condition or environment. Thus, even if admitted or kept for observation, this does not change the fact that this is still a limited stay. It will be the family’s responsibility – not just that of the hospital’s alone – to ensure a safe and successful discharge.

We strongly recommend a minimum of daily visits when someone is hospitalized to keep up with the ever-changing direction of care and services in this acute setting. It is also recommended that someone plan to be with their loved one at time of discharge. If the family is unable, it is often critical to find coverage elsewhere for frequent visits and discharge presence – such as through Aging Life Care Management services.

It will be important to know what is happening in the hospital and why – which may include testing, medication changes, restraints, surgeries, procedures, etc. This also allows the frequent discussion of how this hospitalization, any treatments, and the condition will need to be cared for beyond the walls of the hospital upon discharge. One of the major and continued discussions should be on any medication changes necessary to stabilize the condition. This could be adding on or removing medications. It could also lead to re-doing the way that medications are to be handled in their home environment.

After some hospitalizations, it may be important for the person to have a temporary change of environment to ensure they are safe and rehabilitating well. This may include a stay in a skilled nursing center (which Medicare will cover under certain eligibilities), a step-down stay in an assisted living, or staying with their family until stabilized. On other occasions, it is necessary to initiate discussions on the benefits of further services or a changed environment – such as entering into an independent or assisted living. Hospitalizations can often be the crux for those difficult, but vital, conversations as a family.

Upon discharge – often certain services such as home health care, home care, or equipment such as a wheelchair, oxygen, or a hospital bed will help to reduce risks. It is also important to know how they will handle the basics of household tasks – which include cleaning, laundry, retrieving mail, buying groceries and preparing meals, lawn maintenance, transportation, trash, etc. Occasionally, only temporary help is needed until their loved one is better able to handle the tasks.

As a resource, you may want to reference the hospital discharge planning checklist published by Medicare at –

Wishing the best to you and yours!   Lisa

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