Hospital Discharge Planning: A Guide for Families and Caregivers

When it comes time for your loved one to leave the hospital, many considerations are necessary. This stage in the healing process can be just as important as the in-hospital care, and is susceptible to many pitfalls due to lack of oversight. Hospital discharge planning is the structured and adaptive approach to this transitory stage in the patient’s treatment. It is a team based approach, which can include a patient’s doctor, caregiver, family members, physical therapists, social workers and much many others. It is adaptive in the sense that every patient’s particular necessities such as rehabilitative care, medication, referrals, palliative care and transportation are taken into consideration. The key to successful hospital discharge planning is to give due consideration to all of its aspects, double check everything with specialists, and above all listen to the patient.

Hospital Discharge Planning

The Importance of Adequate Discharge Planning

At its best, hospital discharge planning will decrease the likeliness that the patient is re-admitted, that recovery continues unimpeded and a reduction of healthcare expenses. Even though organizations such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the American Medical Association have put forth recommendations on hospital discharge planning, the process remains generally unregulated. According to the JCAHO, the root causes of ineffective transitions of care have to do with inadequate communication, patient education and accountability.

The Discharge Planning Process

Discharge from a hospital comes at the doctor’s discretion, and usually involves a conversation with yourself as a family member or caregiver, the patient, and other specialists such as translators, social workers and discharge planners. Unfortunately, and due to the unregulated nature of the process, some hospitals approach the discharge planning stage with a level of confidentiality and will opt to exclude you if you are not registered or certified through certain channels. The U.S. Department of Health and Human Services suggests that you pre-empt this and other discharge planning difficulties by asking questions from the very beginning, when the patient is first admitted. Important aspects to look out for in the hospital discharge planning process which may include:

  • A medical evaluation that will comprehensively layout the patient’s condition, both physical and psychological, a short and long term outlook, and any further treatments which the doctor may consider medically necessary.
  • An overview of what the patient’s insurance plan will cover, including financial assistance for the caregiver, the cost in-home medical equipment and the fees incurred from healthcare facilities or medical specialists.
  • A transfer plan to the patient’s home or facility should include an explanation of the patient’s mobility limitations and how those will be overcome. Discharge planning often involves the selection of a health care facility on the spot. It is crucial for you as the caregiver to research these facilities before discharge planning begins to determine the quality of the facilities available, and whether or not they are covered under the patient’s insurance.
  • A determination of the caregiver's responsibilities is absolutely essential and will inform you if any special training or certification is needed. Carefully compare these duties to your own responsibilities to determine if you are up to the task or require assistance as a caregiver.
  • Referrals to adequate home-care agencies, facilities, specialists, support organizations or medical equipment are an essential part of hospital discharge planning. It is at this point that you should be the most vocal about your loved one’s needs to be sure they are covered under their insurance plan.
  • A detailed schedule of follow-up appointments, medication, prescription frequencies and progress expectations is a must. As a caregiver, adherence to the treatment plan is one of your chief priorities. Remember to acquire written materials in a language appropriate to the patient.
  • A reconciliation between the medications to be taken at home and those used during in-hospital treatment should be addressed to avoid possible side-effects or heavy withdrawal.
  • A diet plan and exercise regimen should be discussed with the doctor. Take notes so that you remember these details when meeting with physical therapists or nutritionists.

If you don’t feel like discharge is the best option for the patient, this is the time to voice that concern. If the doctor opts for a discharge anyways, the patient will be responsible for any fees that may arise from an extended hospital stay. You can file a formal appeal for a hospital discharge through the U.S. government using the Centers for Medicare and Medicaid services website.

Caregiver role in discharge planning

Role of the Caregiver

As a caregiver or responsible family member, your role begins as soon as the patient is admitted to the hospital. As it is stated above, many of the decisions that dictate your loved one’s options after discharge are made during at the time of hospital discharge planning. It is important to familiarize yourself with the patient’s condition, their insurance plan and the many health care options as early as possible. The role of caregiver is very important but also difficult.

  • You will be assuming a significant amount of responsibility, therefore your own living situation and needs have to be carefully considered to determine just how much you could realistically sacrifice physically, emotionally and financially.
  • You may be required to receive special training such as the treatment of wounds, the application of topical treatment or dressings, the administering of feeding tubes or catheters, or the appropriate way to handle a physically fragile patient.
  • You must often be a source of patience for your loved one, who may be in a hurry to get home after a long hospital stay, or having problems adjusting to new disabilities.
  • Patients with memory loss or cognitive problems as a result of Alzheimer’s disease, stroke or old age require a lot more attention and help with medical bureaucracy and paperwork.
  • Many patients with serious illnesses, disabilities and those who are vision or hearing impaired may require assistance with eating, dressing, bathing, grooming and toilet use.
  • Help with household activities is essential for some patients. This can include cleaning, laundry, cooking and grocery shopping.
  • Medication management is a big part of the caregiver's role that requires focus and mindfulness. As a caregiver you may have to administer injections, maintain prescriptions or handle appointment scheduling.
  • The caregiver is the patient’s representative and often the person with the most personal and historical information on the patient.

Recovery after hospital discharge

Recovery Tips

Communication with your health care professionals is of the utmost importance during this stage, and only they can say for sure what activities or treatments can lead to recovery. The following tips however, represent generally accepted common sense for caregivers and patients after a hospital stay.

  • Exercise is always healthy and a very motivating activity that can be adapted to most patient’s physical limitations.
  • Companionship works wonders for quality of life and can be found in conversation, socially engaging activities, family visits or the acquisition of a pet.
  • An Emergency Contacts List should be extensive and easy to locate.
  • Weekly Progress Reports on the patient’s condition are easy to compile daily and can help you determine which health care approaches are working best.
  • A Neat Patient Care Space with enough room for medical equipment or at-home visits from specialists. Hazards like excess electrical cords should be tucked away or removed.
  • Stay Up-To-Date on the latest healthcare facilities and treatment methods, as well as changes or additions to the patient’s insurance plan.

Community Organizations and Facilities

A simple search for local organizations can turn up a lot, but don’t stop there. Ask your patient’s doctor, discharge planner, insurance representative and even family members for ideas and recommendations. Many of these organizations can take a big burden off of the caregiver by providing the following:

  • Transportation
  • Hot Meals
  • Counseling (Psychological or Spiritual)
  • Support Groups
  • Senior Centers
  • Case Managers
  • Rehabilitation and Nursing
  • Culturally Engaging Activities

The process of healing can be a precarious one, this is further exacerbated by radical inconsistencies in how different hospitals approach discharge planning. There exists very little obligation for hospitals to provide extensive services in this regard to their patients or any consideration to you as a family member or caregiver. Awareness continues to grow for the roles that families play in a patient's long term health care, but until then it is very important for you to adopt a proactive approach. With the careful consideration of your options you may reduce the patient’s chances of readmission, avoid medicinal side-effects and help to promote their quality of life.


Need Help with Discharge Planning?

Mavencare offers high quality and affordable discharge planning and in-home care services. Give us a call at 1-800-856-2836 to discuss how your family and loved one may benefit from discharge planning and in-home care. You can also have a care coordinator contact you for a free home care assessment.