No matter the reason, having a loved one admitted to the hospital can be concerning. As such, it is often a relief when they are ready to be discharged and set to make their transition back home.

However, proper care and caution must be prioritized in order to ensure that your loved one can make a full recovery. This is especially important, because patients are sometimes discharged from the hospital too soon. That said, if your loved one’s transition home is not handled correctly, then they may not make a full recovery. It can even result in your loved one being readmitted to the facility they had just left.

No one wants to suffer a setback, so it is crucial to have a proper discharge plan in place. Studies show that a patient’s outcome improves when thorough discharge planning has been done and closely followed by the discharged person. This also lowers healthcare costs and reduces the chance for readmission to the hospital.

Patients, family members, and caregivers all play important roles in the recovery process, so it is important for everyone to understand discharge planning and the home care needed when making the transition home.

What is Discharge Planning?

According to the Centers for Medicare & Medicaid Services, discharge planning is “a process used to decide what a patient needs for a smooth move from one level of care to another.” Examples of such transitory care can include returning home from the hospital or going back home after residing in a nursing home or assisted living facility. Home care is often an integral part of a successful discharge plan.

While a patient’s discharge from a facility can be authorized only by a doctor, the actual discharge planning is often done by a nurse, social worker, case manager, or another individual. However, a discharge plan is ideally created by a team with input coming from various sources.

What Should Be Included in a Discharge Plan?

Patient Evaluation

The patient’s doctor or other qualified personnel will assess your loved one’s condition. There should be mention of necessary medications and clear dosage instructions, essential medical equipment, diet restrictions, actions to avoid, potential issues, emergency contact information, and other things of that nature included in the evaluation.

Primary Discussion

Following the evaluation, the individual handling the discharge plan ― whether it is a nurse, social worker, or another individual ― talks with the patient and/or their representative, presenting them with information from the evaluation. If applicable, new medications will be explained and the patient might be referred to physical therapy (PT), occupational therapy (OT) and/or speech therapy (ST). The discharge date, care needs, and other essentials will be covered as well.

Transfer Plan

The discussion continues by deciding how to move forward with the patient’s release, where they will be transferred to, and how they will be transported to their next location. Some patients will be returning home following their stay while other patients may go back to an assisted living facility.

Living arrangements and any medical equipment setup also need to be organized. This ensures there are minimal issues upon the patient’s arrival at their next location. You do not want your loved one to get home only to realize the living arrangements cannot sufficiently meet their needs.

Post Facility Care and Referrals

Once the transfer has been planned, the care needs to be coordinated.

If the patient will be returning home, then a discussion regarding home care plans should take place. Depending on the patient’s specific situation, they may require specialized after-surgery care or even home health care services. Family members can often help in some regards, but relatives are not always qualified to provide the more extensive care their loved ones need. The patients may require help that only a professional can provide.

In such a situation, the facility may refer the patient to different home care agencies and other support organizations that might be helpful.

Follow-Ups

Often after undergoing a procedure or spending time at a hospital or care facility, the patient needs to come back in for a follow-up appointment or to do additional testing. So make sure your loved one has the necessary follow-up appointments scheduled.

Hospital Sitters

If your loved ones must spend extended time in the hospital after their surgery or transfer to a different care facility, they can receive supplemental care from our patient sitters. Caregivers who provide hospital sitting services can give personal care and companionship to patients as they are treated by their nurse or doctor at a hospital or facility. Hospital sitters are also patient advocates but they do not replace the care that is the responsibility of the doctor or nurse.

In addition, our caregivers will ensure that the client lives in a clean environment, is hydrated, eats regular and nutritious meals, and is engaged in social interactions. In other words, your discharged patient will be happy and home with NO hospital readmissions!

Post Hospitalization Care from Assisting Hands Home Care

Data shows home care visits can reduce the likelihood of hospital readmissions as caregivers make sure that your loved ones going home follow the discharged instructions faithfully, including:

• Follow up medical appointments – the caregiver will make the recommended appointments and provide transportation to the appointment,
• New prescriptions – the caregiver will buy any new prescriptions and remind clients to take their meds, and
• Provide coordination with Physical, Occupational, and Speech Therapy, as prescribed, and make sure clients follow these exercises as indicated.

If you have a loved one who is staying at the hospital but will soon be making the transition home, consider working with Assisting Hands Home Care when you go over the discharge planning process. We provide transitional care services in Boynton Beach, North Palm Beach, Palm Beach, Palm Beach Gardens, and West Palm Beach, FL, to assist adults and elderly individuals who are making the transition home from a hospital or rehabilitation facility.

At Assisting Hands®, our in-home caregivers can assist with a myriad of tasks and activities. We can provide transportation home, schedule follow-up appointments, pick up prescriptions, and coordinate with therapists. We can also set up the home for the transition, organize medical equipment delivery, provide home care assistance, and help with light household tasks among others.

In addition, our caregivers will ensure that the client lives in a clean environment, is hydrated, eats regular and nutritious meals, and is engaged in social interactions. In other words, your discharged patient will be happy and home with NO hospital readmissions!

With help from the in-home caregivers at Assisting Hands, your loved ones will have the home care they need to make a seamless transition home and make a full recovery.

For more information about discharge planning, check out Medicare.com