One of the most important parts of an older adult’s hospital stay is the discharge plan. During the hospital stay, friends, family, and hospital staff are focused on what is happening in the hospital during treatment. Often the plan for what happens afterward is made just a few hours before the person goes home. If you are one of that person’s caregivers, you can get ahead of the curve by planning transportation and home care and nursing well before the discharge time.

Without a plan, people coming out of the hospital are likely to suffer from medication errors, contract an infection, relapse with an illness, or have a fall. The result for almost 20 percent is re-hospitalization within thirty days of release.

Until recently, hospitals gave very little guidance on organizing post-discharge care. They saw their job as acute care: administering medication, monitoring the effects of medication or surgery on the patient, gauging the patient’s progress and recovery.

In addition, some Federal regulations put them at risk of being accused of conflict of interest if they recommended a facility they owned or had a close partnership with. Family and friends might be handed a list of nursing homes, skilled nursing facilities, or home care solutions in the same pile as the medication schedule and the post-hospital care instructions, but with very little comment on how to choose.

But a new rule by the Centers for Medicare and Medicaid Services is changing that. Under the rule, hospitals must provide information about local providers and their performance in post-acute care and discuss the trade-offs between different kinds of care. They must facilitate a smooth exchange of information about the patient between the hospital and the next team of caregivers and ensure that a patient’s information follows them after discharge. And they must conduct a discharge planning process that focuses on the person’s health goals and treatment preferences.

The provides a simple but complete guide to making a discharge plan that includes home care and nursing. A good discharge plan treats the friends, family, and any regular caregiver as part of the team, as well as medical professionals and the person’s regular doctor. If your loved one has memory problems caused by Alzheimer’s disease, stroke, or another problem, you will need to be a part of all discharge discussions. You may need to remind hospital staff about special care and communication techniques your loved one needs. Even without memory problems, older adults often have hearing or vision problems or are disoriented when they are in the hospital. A close friend or family member can make these conversations easier.

The discharge plan should include information about medications and diet, what activities the person might need help with, what extra equipment might be needed, such as a wheelchair, commode, or oxygen, who will handle meal preparation, transportation and chores, and referral to home care solutions needed.

The Family Caregiver Alliance lists simple measures that will keep an older adult safe and assured of getting better.

  1. Make sure a follow-up appointment has been arranged before your loved one leaves the hospital.

  2. List all the medications the person is taking and make sure that all the doctors involved have compared the medications taken before hospitalization with those prescribed afterward to prevent duplications, omissions, or harmful combinations.

  3. Have a telephone number accessible 24 hours a day, including weekends, for care information.

Home care agencies can help create and carry out the post-discharge plan. At CarePlus Home Health, for example, the provides prescription pick-up and medication reminders, range of motion exercises, transportation to medical appointments, grocery shopping, meal preparation, assistance with eating and getting in and out of bed, laundry, light housekeeping, and general assistance with carrying out the discharge instructions.

If the person coming out of the hospital needs special care like wound dressings, rehabilitation services, tube feedings, or catheter care, are also available at home.

Get all the support you need. Talk to the doctor, nurse, or hospital social worker or case manager about a discharge plan. If the older adult in your life prefers to go home and this is medically feasible, feel free to call on CarePlus Home Health, Inc. We provide home care and nursing to Montgomery County, MD and throughout the state. We offer a 72-hour post-discharge program and will be glad to help you and the medical staff set up a discharge plan. Just call us at 301-740-8870 or use our contact form.

We look forward to talking with you and your loved one.