The following questions are commonly asked by patients, family members and caregivers after a planned hospital stay. IntegraCare, an affiliate of Kindred at Home, helped to answer these questions and offer further explanation.

Q: There are usually many key players taking care of the patient, but is there someone that the patient and or family can go to for resources prior to and after discharge from a facility?

A: Case managers are assigned to a patient upon admission and follow the patient until the patient transitions to the next setting. Case managers meet one-on-one with the family and assess the needs of the patient during hospitalization and post hospitalization. They are also available to answer any questions and follow up with concerns from both the patient and family.

Q: You hear a great deal about discharge planning. What exactly is discharge planning?

A: Medicare says discharge planning is, "A process used to decide what a patient needs for a smooth move from one level of care to another." A physician has to be the one to authorize a patient's release from the hospital, but the actual process of discharge planning can be completed by any number of staff members – a social worker, nurse, case manager (or someone else). It doesn’t mean the patient is fully recovered, but only that the physician feels his or her condition has stabilized and doesn’t require the level of hospital care that has been made available to him or her.

On the day of discharge, instructions will be provided by the nurse. The instructions include information about the next physician’s appointment and information and specific instructions, if needed, related to mobility and post-hospital care. A medication list is also included. At this time, the caregivers should review each medication with the nurse. Some medications might be the same while others are new. Medications have different names so during this walk-through with the nurse this information will be disclosed. Medication errors are on the top of the list for rehospitalizations.

Q: What planning should family members begin to consider while the patient is still in the facility?

A: When the patient is almost ready to be discharged, it is very important to make follow-up appointments with the primary care physician and specialty physician(s). During these appointments, medications will be reconciled and prescriptions will be written. Also, any additional questions or concerns can be addressed.

It’s also a good time for the family to prepare the home environment for the patient’s return. Adding safety bars, removing rugs and moving furniture is often necessary. Also, if the patient needs assistance throughout the day this is the appropriate time to get resources in place and schedule. Case managers would be a great resource for referring the family to agencies and companies that meet their specific needs.

Kindred at Home Q: What can the family expect when transitioning to a home setting?

A: When the patient transitions from the facility to the home setting there are many important issues to make the transition smoother and decrease the risk for rehospitalizations.

A good goal for the family/caregiver would be to meet with the therapists during the treatment session. Working with physical, occupational and/or speech therapy can allow the family to determine the amount of assistance that may be needed when the patient is at home. Take notes on how the patient gets out of bed and ambulates to the bathroom, and determine if any additional assistance will be needed at the patient side. The speech therapist can teach the family what specific exercises would be beneficial when swallowing or choking is an issue.

The therapists and case managers will recommend the durable medical equipment and/or supplies that will be needed at home. When transitioning home, sometimes the patient’s strength is lacking, and the patient will need a device(s) for assistance with mobility and safety. Some examples of durable medical equipment are canes, walkers and wheelchairs. If the patient is chair or bedbound, a hospital bed may be beneficial for the patient. Specialized mattresses are available with physician orders for patients with specific needs.

Q: What if the patient needs additional care in the home setting?

A: When further assistance and skilled care is needed at the time of discharge the patient would benefit from home health services. The home setting can be a private residence or an assisted living. Home health services will be provided under the care of a physician. A nurse can provide education with medications to decrease the risk of medication error. Training and education is given to the patient and caregiver to meet the goals developed with the physician and patient. Medical social workers are available to assess social and emotional factors, refer to community resources and to assist with financial issues. Physical and occupational therapy can be provided to treat medical conditions to improve rehab potential. Speech therapists are available to assist with swallowing difficulties and cognitive exercises. A home health aide may be provided for personal care needs when ordered by the physician as an integral part of the plan of care.

Q: What advice would you give a caregiver whose loved one may need this additional care?

A: Be aware that sometimes the patient thinks he or she can do a lot more than they can actually do. They have unrealistic expectations and once they get home it’s a bit too late and they are upset to find they are in fact a lot weaker than they thought. The caregiver needs to have a nurse or doctor evaluate the patient and have this evaluation explained to the caregiver in front of the patient. The patient needs to hear what they can and can’t do. This also helps the caregiver determine how much help the patient will need in the first few weeks after the patient is home. The medication regimen might seems easy in the hospital but is sometimes very overwhelming .

Q: What about insurance? Most people don’t know what medical insurance will pay.

A: Unfortunately, many people don’t find out until the last minute when they need the insurance to pay. Then the patient and family members are shocked to find that some services and items that were covered at the hospital aren’t covered at home. Sometimes short-term in-home care is covered but that’s not a guarantee. So, it’s important to begin to investigate as soon as practical what follow-up care would be paid for and what the patient will pay out of pocket. A discharge planner or social worker can help with that but you need to keep in mind they may not be able to give you all the details about this coverage because it will depend on the patient’s progress at home and other issues that may be insurance specific.

Q: Can the discharge plan have alternative plans of care? Are there choices for care once the patient is at home?

A: Yes. The discharge plan is ideally based on a very careful review of all available options. But it might send the patient to a nursing home that has an available bed, for instance. On the other hand, the caregiver may feel that the nursing home is too far away, or maybe the caregiver doesn’t want to send the patient there. So there are a lot of variables. Although it’s a monumental task, the caregiver may want to do some research or enlist a family member or friend to help them with this task. But everyone needs to remember that you don’t have to settle. If you have any concerns whatsoever, ask many, many questions, and don’t be afraid to ask. Gather all the information you can and then form your own well-informed decision. Communication is key between providers, caregivers and patients. There are also private pay options for paid caregivers to come into the home.

Q: Are there any more tips you can give caregivers to make this a little easier on them after the patient’s hospital stay?

A: Take care of yourself. Caregivers have probably already spent a lot of time at the hospital with the patient and now they are expected to help once the patient is at home. They’ve had things that they have had to do at home that they aren’t getting to and stressing about getting them done.

Take a little time for you. Even if it’s to ask a neighbor to come over and help out for a few hours to give you some relief. Or you can ask the discharge planner to help out by giving you names of community resources that do this sort of thing once the patient is at home from the hospital. Further, there are counselors out there in these centers that can give you emotional help, and you can even get some financial advice. But the point is, take care of you.

And another way …. remember that a home health agency skilled nurse can be instrumental in identifying ways to maximize improvements in the patients while in the comforts of their home, not only through the use of their skill set, but through compassion and caring, allowing the patient to maintain their dignity as well as their independence.