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Hospital Discharge Planning: A Guide for Families and Caregivers

Donald Kreis by Donald Kreis | Licensed since 2002
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This article was updated on: 05/15/2017

When a loved one has been hospitalized for illness or serious injury, it’s normal to have questions about what happens next. Whether the plan is to return home or be transferred to rehab or other care center, a hospital discharge often comes with lots of decisions and moving parts for a caregiver to manage.

Fortunately, at many care facilities, hospital discharge planning is taken very seriously; there may be case managers, nurses, and social workers who work together to prepare both the patient and the caregiver and coordinate the discharge process. Here are some tips from the Family Caregiver Alliance to help you plan for your loved one’s hospital discharge.

What will the hospital discharge planning team do?

An effective discharge plan can help make sure your loved one is safe and her personal and health-care needs are met; usually the goal is to promote a smooth recovery and prevent readmission to the hospital. According to the Centers for Medicare and Medicaid Services (CMS), the hospital discharge team will typically meet with the primary caregiver and other involved family members to address these issues:

  • What is the patient’s health condition? What is the likelihood that he will improve?
  • What medications or medical therapies are necessary? Can the caregiver administer them at home?
  • Are there dietary restrictions?
  • What activities will she need assistance with? Will she need special equipment (oxygen, wheelchair, commode, etc.)?
  • Will he return home or be transferred to another facility? Will the transfer be temporary or long-term?
  • If the patient is returning home, will the caregiverneed any special training or assistance to handle the patient’s needs?
  • Are referrals for home health or community support agencies appropriate?
  • What type of follow-up appointments and tests will be needed?

The answers to these questions might form the basis of the hospital discharge plan, which may include discharge orders and recommendations for both the patient and the caregiver.

What is my role as a caregiver in the hospital discharge process?

If you’re a caregiver’s spouse, partner, or close relative, chances are you are the expert about your loved one’s home situation and the advocate for his care. Be aware of the challenges you may face and your own abilities and limitations in providing the specific care your loved one needs. Dad may refuse to swallow pills at home, for example, or you may have physical limitations that prevent you from lifting him or turning him in bed.

It is important that you be honest and direct in expressing your concerns during the discharge planning process, says the Family Caregiver Alliance (FGA) website. If there is highly specialized care required, such as wound care, an ostomy pouch, or a feeding tube, make sure you understand what needs to be done and feel comfortable performing the tasks. If you don’t, ask for extra help and/or training.

As a caregiver, whether your loved one is returning to her own home or moving in with you after discharge, the FGA suggests that you may need to make arrangements to handle basic needs such as:

  • Personal care (toileting, bathing, dressing, eating)
  • Household tasks (laundry, cleaning, grocery shopping, food preparation)
  • Tasks related to health care (managing medications, getting the patient to and from medical appointments, arranging for any necessary medical equipment)
  • Emotional support (companionship and meaningful activities)

FGA suggests that you make sure your hospital discharge plan addresses any of these needs that applies to your situation, and don’t be afraid to advocate for an appeal to a discharge decision if you feel that discharge is happening too soon, or that the plan is incomplete.

What if my loved one is being discharged to another facility?

Even if your loved one isn’t coming straight home after a hospital discharge, as a caregiver, you can still have an essential role in the process. Here are some things to consider (from the National Institute on Aging and the Family Caregiver Alliance):

  • How does the facility rate in the government’s Nursing Home Compare database?
  • See if you can visit the facility before your loved one is transferred there. Do the residents seem well cared for? Is the staff attentive and caring?
  • Ask how long the director and other facility personnel have worked there. A high turnover might not be a good sign.
  • Is it convenient for you and your family members to get to? Do the visiting hours fit your schedule?
  • What is the anticipated length of stay?
  • Is the food culturally appropriate and are there people on staff who speak my loved one’s language?
  • What therapies and treatments will my loved one receive?
  • What are our financial responsibilities at this facility?

Remember, hospital discharge planning is a process that should ideally begin as soon as your loved one is admitted and involve the caregiver and family members every step of the way. It’s OK to ask lots of questions and get clarification on anything you don’t understand or feel is not appropriate for you or your loved one.

This article is for general information only and may not apply to your circumstances. This article should not be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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