What You Need to Know About the Hospital Discharge Process to Help Your Loved One!
When an aging parent is hospitalized due to a fall, stroke, pneumonia, or another serious condition, the focus is naturally on their immediate medical needs. However, as hospital stays become increasingly shorter, families often find themselves unprepared for what comes next. The discharge process can be overwhelming, and the decisions made during this time are critical to the ongoing care and recovery of your loved one.
Hospital Admission
I know this article is about the discharge process, but part of a successful discharge starts at admission. It's vitally important that during the initial discussion with any of the health care providers upon arrival that all information about the patient be made available. They need to know what happened, the patients history and medications, etc. Inaccurate or missing information could result in:
- Delayed diagnosis
- Duplicatived services - something was already addressed prior to admission
- Hospital readmission after discharge because the correct issue wasn't addressed
- Reduced patient and provider satisfaction
The hospital and health care providers want to provide the best care possible and avoid readmissions. Did you know that 20% of Medicare patients are readmitted within 30 days of discharge? Your knowledge, advocacy and planning are key to help prevent that.
[Check out the File of Life. This handy document contains much of what you would need at admission, plus, it's a wonderful document for first responders.]
The Hospital Discharge Process: What to Expect
The average hospital stay is now only about three days, a significant reduction from years past. This accelerated timeline means that families need to be proactive from the moment their loved one is admitted. In fact, once a patient is admitted, the hospital is planning their discharge. Much of this is based on diagnosis, the doctor's recommendations and insurance.
Start the Conversation Early
As soon as your loved one is admitted, it’s crucial to start communicating with hospital staff about the discharge process. Find out who will be helping with the discharge. Is it a social worker, a discharge planner or a case manager? Knowing the terminology will get you to the correct person and hospitals might use any of the above. These professionals will be your primary contacts and will help coordinate the transition from hospital care to the next stage, whether that be home care, rehab, or another facility.
Once you know who to speak with, make contact as soon as possible. You may only have 3 days to put plans in place and waiting until day 3 will be a mistake.
It’s essential to keep these lines of communication open and responsive. Hospitals often encounter delays simply because they can’t reach family members to discuss discharge plans. In other words, answer the phone when they call! Once they leave a message, they move onto the next case or issue and you could end up playing a game of phone tag. Being available and proactive can make a significant difference in ensuring a smooth transition.
Assessing Your Loved One’s Needs
One of the most critical aspects of discharge planning is assessing the ongoing needs of your loved one. Be willing to share detailed information about your parent’s living situation and capabilities.
- What your loved ones home is like: Are there steps? Can they get to a bathroom easily? Where is the bedroom? Is it adapted to aging-in-place or can it be? Is the home safe to return to?
- Home Care: Is there someone there to care for them? Is that person capable of caring for them? If not, could they care for themselves once discharged? Is there food in the refrigerator? Could meal delivery be an option? Can home health care or physical therapy come into the home?
- If they are not in their own home, is the Assisted or Independent Living Community able to provide the services they need? So they have rehab services?
- What's happening with your loved one? Were they already having difficulty with taking care of themselves before the hospital stay? Could they use some help or services and be willing to accept them? What was the cause of the hospital stay? Are there any new cognitive issues that you've noticed?
This is a small sample of what the conversation could include. The more information you provide to the hospital staff, the better they can tailor the discharge plan to meet your parent’s specific needs.
Understanding Discharge Options
When it comes time for discharge, several options may be on the table:
- Home with Home Care: For patients who are stable enough to return home but still require some level of medical care or assistance with daily activities.
- Inpatient Rehab: Ideal for those who need intensive physical therapy, typically providing three hours of therapy per day over 10 to 14 days.
- Skilled Nursing Facility (SNF): Provides a slower-paced rehabilitation process, often one hour per day of various therapies, and is suited for those who may not be ready for the intensity of inpatient rehab.
- Acute Care Hospital: For those who need complex medical care, such as long-term IV treatments, which cannot be provided in a typical home or rehab setting.
- Senior Living with On-Site Care: Some senior living communities offer on-site therapy and medical services, blurring the lines between traditional senior living and skilled nursing facilities.
Advocating for Your Parent’s Needs
It's important you are on top of what is happening so you can advocate during the discharge process. While the physician’s recommendation is a key factor, it’s not the final word. Families can and should advocate for the level of care they believe is most appropriate, especially if they feel that the recommended plan does not fully address their loved one’s needs.
For example, if the hospital recommends skilled nursing care but you believe your parent would benefit more from intensive inpatient rehab, it’s essential to communicate this as soon as possible. If the recommendation is to go home and you know they are not strong enough or have enough support at home, then perhaps you can advocate for in-patient rehab or a skilled nursing facility stay. Ask to see the hospital therapists and get them on-board with that recommendation. If the recommendation is a skilled nursing facility and you know they are determined and willing to work hard at home with therapy coming into the home, then advocate for that. As you can see, you can advocate on behalf of your loved one and possibly change the outcome of the recommendation. Often, the success of such advocacy hinges on understanding your parent’s insurance coverage and how it influences the options available. Plus, be sure to check that insurance will cover whatever option you choose or your loved one could have to pay from out-of-pocket.
For example, if the hospital recommends skilled nursing care but you believe your parent would benefit more from intensive inpatient rehab, it’s essential to communicate this as soon as possible. If the recommendation is to go home and you know they are not strong enough or have enough support at home, then perhaps you can advocate for in-patient rehab or a skilled nursing facility stay. Ask to see the hospital therapists and get them on-board with that recommendation. If the recommendation is a skilled nursing facility and you know they are determined and willing to work hard at home with therapy coming into the home, then advocate for that. As you can see, you can advocate on behalf of your loved one and possibly change the outcome of the recommendation. Often, the success of such advocacy hinges on understanding your parent’s insurance coverage and how it influences the options available. Plus, be sure to check that insurance will cover whatever option you choose or your loved one could have to pay from out-of-pocket.
The Role of Insurance in Discharge Planning
Insurance, particularly Medicare, plays a significant role in determining discharge options. The type of Medicare plan (traditional Medicare, Advantage plans, PPOs, HMOs, or supplemental insurance) can affect what services are covered and where your parent can receive care. Keep copies or pictures of your parent’s insurance cards readily available, as you may need to refer to them frequently during the discharge planning process.
Preventing Readmissions and Transitional Decline
One of the key goals of effective discharge planning is to prevent hospital readmissions. Unprepared discharges often lead to readmissions within 24 to 48 hours, particularly when the home environment cannot support the level of care needed. It's vitally important that if someone says they can care for the patient in the home, i.e., an elderly partner, that they truely can! Each transition—from hospital to rehab, from rehab to home—carries the risk of causing a decline in the patient’s condition, especially if they have cognitive impairments such as dementia.
A few keys to successful transitions are:
- Medication Management
- Transition Planning
- Patient/Family Engagement & Education
- Communication & Transferring Information [is someone being a gatekeeper?]
- Follow up Care
Also, do the caregivers know what the red flags are that indicate a worsening of the loved one's condition and how to respond to them. If it is a serious red flag, the 'wait and see' option could lead to a readmission or other consequences of a delay.
Planning Ahead
You need to plan ahead before a medical crisis occurs. Families should familiarize themselves with nearby rehab facilities, skilled nursing options, and senior living communities that might be suitable for their loved one. Having a plan in place can prevent the stress and uncertainty of making these decisions under pressure. Just realize that your first choice may not be possible. But also advocate or put your foot down that your last option is definitely NOT an option. You will only know that if you are familiar with what the options are and which ones to avoid.
Final Thoughts
Discharge planning is a critical yet often overlooked aspect of caring for an aging parent. By understanding the options, communicating effectively with hospital staff, and advocating for your loved one’s needs, you can help ensure they receive the appropriate care and avoid the pitfalls of an unplanned or rushed discharge. Being informed and prepared can make all the difference in your parent’s recovery and long-term well-being.
For more information or help with your loved one, please reach out to Sage Senior Transitions at (717) 644-3812.
Disclaimer: This webpage provides general information and guidance. Individuals should consult with professionals and relevant authorities for personalized advice and recommendations based on their specific circumstances.