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Helping You with a Smooth Health Care and Hospital Transition to Home

May 12, 2010

Helping You with a  Smooth Health Care and Hospital Transition to Home

<em>If you are having loved ones who are frail or aging and you are their sole caretaker, this column is for you. </em>

Most of us don’t plan ahead for emergencies or hospital events.  Why? Because it is not something we like to think about, nor is it a system that we commonly navigate.  Because of this many otherwise well educated folks are often left scrambling on the day of a hospital discharge trying to find placement options for their loved ones or to organize a home solution. This dilemma will eased overtime by the hospital’s reimbursement being tied to successful discharges that do not require readmission, however ultimately your and your loved ones best interests will only enhanced with expectation and   good communication of what lies ahead.

Why is it important to know what lies ahead you say?  I don’t even know if my mom will be able to walk after her broken hip.  Well, odds are you may not know if or how well she will  walk but what we can help you with is what will be the questions you need to ask to determine how soon to plan the discharge and what options you have so you can mentally get ready for whatever happens.

Most hospitalization will ultimately end in a discharge.  The health status of the person once the acute medical episode is over will determine where they will be discharged.  If you or you’re loved one needs ongoing rehab or 24 hour medical supervision, the discharge will most likely be to a rehab unit or a skilled nursing unit. Rehab units are intended primarily for those with more catastrophic events like a stroke or brain injury while simple fractured hips often receive 21 – 30 days of skilled nursing care followed by home health and home care if there is a need for personal care.

However one thing for sure is that you will need time to prepare for the discharge and the day before or day of discharge does not make for a smooth transition as emotions and level of comprehension are difficult to garner at these critical times.  So how do you make a list or questions to prepare for the discharge? Additionally what should be your expectations?

The following is a general guide but can be tailored more to your situation.

1.  At what level of medical improvement or status will I or my loved one be discharged?

(In essence describe for me what you will see in laymen’s terms- like 3 days post op or the ability to stand, to ability to eat, no fever and then you can go home etc.)

2. What discharge options will I qualify for with my condition?  What is the lead time for referral to these sites?  Do I have a say so in which one I go to? (In essence are there 3 skilled nursing centers who will take me but really one with beds?

3.  Can I get the list of the discharge sites that probably I would qualify for  so I can see them ahead of time and inquire how  the reimbursement ( insurance or Medicare)  and co pay may work?

4. When I am discharged what equipment will I need and is it paid for by my insurance or Medicare? Will it get there for my discharge or arrive sometime latter and who is the contact and how is it billed.

5. If am to be sent home rather than to another level of care what should I expect?  Will I get new prescriptions, equipment and will they are ready at my discharge or will the equipment be delivered.  How will I know if the equipment will work in my house and is there a list of standard items like shower chair, walker or wheelchair I qualify for?

6.  Who will go over my discharge instructions?

7.  If I get home health or hospice ordered how long does it take for them to come out?  Who is the contact and if they do not call me what do I do?

8 .If I need home care to help with my loved one how that is different from home health or hospice and who pays for that?  Can I interview them prior to discharge?

9. Who will tell me when to return to the doctor after discharge?  Who is monitoring me after I leave especially if I have an in hospital doctor who does not know my regular doctor?

10.  When I get home and if I get sick or my new medicines make me sick or are not working what do I do?

These are a few of the key question you need to know to plan your discharge.  However how you adapt to the discharge will also be dictated to how soon you ask the questions and form your expectations of what should happen and how you will manage the situation.  You need to know what comes next even if you never have to use that option.  You need to know and expect that you will have access to care and equipment in a timely manner and who to call if that is not happening. You should expect that you or your loved one be given proper information for communicating with your primary care doctor and or specialist so that there is no questions regarding your ongoing medication regime or treatment needs. You need to know when to call regarding problems or return check to the specialist or your primary care doctor. Your expectation is that you should have all the information you need to direct your care in a timely and safe manner.  There should not be loop holes where you are not sure what precautions or side effect to anticipate after discharge or what medications are correct or need to be added or deleted.

The continuum of discharge options is a maze to navigate and there are many helpful professionals out there who once they know your discharge plan can help you. CaraVita Home Care can help you if there is a discharge home and the personal care needs exceed what you as the caretaker can provide on a 24 hour basis. We can help you manage the discharge, your medication and coordinate with home health and your physician. Our nurse care manager can help you ask the right questions so that you can form good expectations for discharge and home care. Whether you need 2 – 24 hours of care daily or several times a week, we want to be your partner to restored help or ongoing support.

Give us a call and let us see if we can help you, today.  770-643-1712 our line is manned 24 hours a day.


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