National Family Caregivers Association

Wednesday Jul 9, 2008

Discharge Planning Begins at the Time of Admission Patricia L. Tomsko, M.D., and Sandy Padwo Rogers

Your loved one has just entered the hospital. It may be for a routine procedure or a serious complication of his/her chronic illness. In either case, you immediately begin to focus on how to make the hospital stay as comfortable and stress-free as possible. Before you even have time to catch your breath, however, you're informed that it's time to discuss the hospital discharge. "How can that be?" you ask. "They haven't even removed the IVs yet. Is this a mistake?" Unfortunately, the answer is usually "no." With hospital stays growing shorter each year, the time to begin discharge planning is at the time of admission.

For caregivers, the hospitalization may serve as your first real break away from your caregiving duties in some time. While it's important to serve as your loved one's advocate during this time, it is equally important to take advantage of this break by allowing yourself some time away from the hospital.

It's important to remember you are not alone at this time, and assistance is available to help you make the difficult decisions regarding "what's next?" It is the job of the hospital discharge planner to work with you to ensure that your loved one receives appropriate care upon leaving the hospital. The discharge planner can ease the shock of learning that your loved one's discharge is imminent. These individuals can also help you make the critical decisions with which you are suddenly faced. There are a few things you can do to help facilitate the process.

Be proactive. As soon as your loved one enters the hospital, ask the attending physician how long you can expect that he/she will remain there. Tell the physician and the hospital unit secretary that you wish to speak to a discharge planner/case manager as soon as possible, so that you can begin making arrangements for whatever continued care is necessary. Discharge planners and case managers find their time consumed with patients who are leaving the hospital "that day." By asking for a consult right away, you can become a partner in the discharge process.

Find out what your insurance covers. The discharge planner can help you find out what your loved one is entitled to under your insurance. Specific medical criteria must be met in order for a nursing home stay to be covered. The same goes for coverage of various home health aides and durable medical equipment. Let the discharge planner make these calls for you, so you can concentrate on the important decisions you must make. It is also important to talk to your discharge planner about whether or not ambulance transport is needed for your loved one. Depending on your insurance, this service may or may not be covered. Many families are shocked to receive a bill, which can run into the hundreds of dollars.

Share information. Be prepared to inform your discharge planner about your loved one's health history. In addition, the discharge planner will want to know about your loved one's activities before the hospitalization, in order to better assess what services and/or equipment you might need to help you in your caregiving duties. Often, your loved one will have more needs upon discharge from the hospital. For instance, before the hospitalization, he/she may have been able to stand and pivot during transfers. After the hospitalization, full assistance may be needed. If your house or apartment has narrow doorways or steep, curving stairways, a hospital bed or other durable medical equipment may not fit in your home. Make sure your discharge planner knows about these barriers to care.

Put together a list of any skilled nursing (rehabilitation) facilities or home health care agencies you have previously used, and discuss which ones worked for you and why. For many patients, discharge from the hospital does not mean an immediate trip home. Today, a skilled nursing facility is an extension of the hospital and is often the next step in your loved one's recovery. Your discharge planner will provide you with a list of Medicare- and Medicaid-approved skilled nursing facilities or home health agencies in your area. The planner will also contact those you choose to determine which ones have openings and/ or available equipment and staff.

Home health agencies offer a variety of services, including certified nursing assistants, LPNs, RNs, physical therapists, occupational therapists, speech therapists, dieticians, and sitters. Find out which of these services were ordered for your loved one.

Make sure you get a demonstration on how to use all durable medical equipment. A bedside lift (sometimes referred to as a Hoyer lift) is useless if you don't know how to use it for transfers. If your loved one is a diabetic or requires other specialized treatment or care, even if you had training in the hospital, an educator coming to your home when you and your loved one are less stressed may be useful. The training you get in the hospital often doesn't translate to quite how you'll have to perform a task or procedure in your own home.

Do research as soon as you can. You will want to check out area facilities and/or agencies before the day of discharge is upon you so you don't feel rushed into making a decision. Talk to family members and friends, and arrange to tour several facilities while your loved one is still in the hospital. Have a backup choice in case the one you pick is full. Talk to your physician about who will be providing care to your loved one at the facility you choose. Many physicians don't make rounds at nursing homes, and so your loved one will most likely be seen by another physician while there. This shouldn't be a problem if you are looking at a short-term placement. Some hospitals run their own skilled nursing facilities within the hospital complex. The discharge planner will tell you if your hospital does, and if these beds are available. Keep in mind that before any transfer, the physician providing care in the hospital is responsible for preparing a discharge summary. The discharge summary should include a description of the hospital course of treatment, a list of medical problems and medications, and rehabilitation instructions. Ask the discharge planner for a copy of this document for your records. Make sure you understand what is being asked of you and whether or not you believe you can do it.

Ask for help. It is natural to feel that your loved one is being discharged before either one of you is ready. Remember, hospital stays are much shorter than they used to be. It is also likely that your loved one will have special medical needs that will continue beyond the hospitalization. The discharge planner is there to help make all the necessary arrangements for transfer to a skilled nursing facility, for the use of home health equipment, or for health aides in your home. Don't be afraid to ask for this assistance, and don't be afraid to speak up for what you truly believe is necessary for your loved one's health and safety-and your own.

The day your loved one enters the hospital is usually not the time you are thinking about discharge. But in this era when the hospital is viewed as just the first stop in the healing process, it's never too early to begin planning for the next one.

Patricia L. Tomsko, M.D., is board certified in family practice, geriatrics, and hospice and palliative medicine. She is Managing Partner of Rock Creek Geriatric Medicine in Montgomery County, Maryland. Sandy Padwo Rogers is Program Director for Rock Creek Geriatric Medicine.