Healing Better at Home: Planning for Care After Hospital Discharge

Its a startling fact: Twenty percent of the more than two million Medicare recipients who are sent home from the hospital, are readmitted within a month often with more severe health complications, according to data published in the New England Journal of Medicine. Ive seen many families go through this. While its not uncommon for older adults to continue to their healing in a rehabilitation facility for a time after a hospital stay, they often return home before they are fully recovered. They arent quite ready or strong enough to manage the range of complicated care needs they have during recovery. This leaves families scrambling trying to manage multiple medications, wound care, mobility issues, and household chores, while their loved ones recover. During this time, between hospital discharge and full recovery, older adults are more vulnerable and at higher risk for falls, medication mix-ups, infections, and other complications that can lead to rehospitalization and even death. But with some solid planning and the support of a coordinated care team including professional caregivers, family caregivers, discharge planners, and home health nurses and other care specialists, you can minimize the dangers for your loved one and make an easier transition home, says Sara Russell, RN, a senior care specialist and a caregiver trainer and educator.

A smooth transition from hospital to home is essential, particularly for older adults with chronic conditions and complex care needs, according to a review in the American Journal of Nursing. It can ease stress, support healing, and recovery, and make everyone more comfortable. Thats a big reason many families choose to work with our qualified caregivers as they move their loved one home from the hospital. Our caregivers are trained through the Home Care 100 Advanced Caregiver Training Program in safe transfers, medication reminders, meal preparation, and other specific and complex care needs often required by patients after a hospital or rehab stay. We regularly drive and accompany our clients to medical appointments and can take detailed notes of the meeting for family members who cannot attend. This ensures that your loved makes their follow up visits which are key to recovery. Could a professional caregiver be helpful to your loved ones recovery? Its something worth considering as part of the discharge planning process.

How to Plan for Hospital Discharge

Discharge planning might begin soon after your loved one is admitted to the hospital. Hospital planners will sit down with you, your loved one, and other family members to begin talking about the kind of care that youll need to provide at home as your family member continues to heal. Theyll discuss things like follow-up care, home health care, which includes visits from a registered nurse or physical therapist to check on the patient, pain and wound care management strategies, and any home modifications that will be needed such as bringing a hospital bed, installing grab bars, picking up area rugs to support the senior. At this point, many families decide to hire a professional caregiver to help them manage the long-list of complicated care requirements older adults often have when they first arrive home from the hospital or rehab facility. Our caregivers can provide short-term support while your family member recovers. Then, as he becomes stronger and more independent, we can reduce or eliminate those care hours altogether to accommodate his changing needs. What else should you talk with discharge planners about? Ask about mobility support, so you know how to help your loved one transfer from bed to bathroom or chairs without risking injury to the both of you. And, medications, prescription schedules, potential side effects, follow-up appointments, and anything else that will influence your loved ones recovery and health. The answers to these and other questions will help you put things in place ahead of time to make the transition home less stressful for everyone.

Questions to Ask Discharge Planners of Hospital Social Workers:

When will my loved one be discharged home?
How will he be transported there?
Will he be able to get and out of the car on his own?
What problems should I expect?
Who do I call during the day and after hours if problems or concerns arise?
How will care and treatment continue after discharge?
Will home health providers nurses, therapists, etc. be coming to the house to provide care?
What medications will he be on and what are some side effects can we expect from the medication?
Will we need any medical equipment at home such as a walker, hospital bed, commode, oxygen tank?
How will I get that equipment and who will install it in the home?
Will my loved one need help bathing, dressing, eating, drinking, showering, toileting or with any other tasks of daily living?
Is there any special care or treatment I need to learn how to deliver such as providing wound care, insulin shots, or other care?

These are key questions I suggest families ask when meeting with doctors and hospital discharge planners. Feel free to print out our handy checklist of these and other questions to ask your discharge planner.

Transitioning Home:

In most cases, some modifications of the home should be completed even before your loved one is released. And this is another way a professional caregiver can help. We work with families to help prepare the home for easy access and will set up the patients room to fit their preferences and abilities. Well make sure the things he most needs and enjoys eyeglasses, hearing aids, phones, newspapers, television remotes are in close proximity. Moving key objects closer is another risk reduction strategy used to prevent seniors from reaching and potentially falling out of the bed or chair. Think of us as your safety net here to help your loved one avoid hospital readmission by making the transition home easier, safer, and a whole lot less stressful for you and your family. When you do arrive home, youre loved one will probably begin working with home health providers like nurses, therapists, and dieticians. Those visits will begin almost right away. You can also expect to have a number of follow up appointments at therapy and medical offices. You and your loved one will need to decide how he will get there and what kind of help youll need to move safely in and out of the car.
Our caregivers often transport clients to medical appointments and regularly work in collaboration with home health providers. A professional caregiver can serve as a bridge between family members, medical providers, therapists, and pharmacists, Russell says. And, also help you establish a supportive daily routine that aids recovery and eases stress and helps your loved one avoid complications.