Chapter 3: Assistance Options
Before discharging from a hospital stay,
IT IS EXTREMELY IMPORTANT
TO WORK ON A DISCHARGE PLAN ASAP AND THAT THE STAFF SHARES
REALISTIC GOALS AND TIMEFRAMES
How this is managed, can significantly impact your loved one’s quality of life and lifespan.
Discharge Planning
starts from admission!
I have witnessed the impact of discharge planning for the good and unfortunately, the bad. Where relatively small practices and implementations could’ve made significant differences; like
whether someone is discharged back home or spends the remainder of their life in a nursing home.
Not to be dramatic;
just clarifying the impact.
The tips below are based on my experience
Experience picks up on those nuances that aren’t always so apparent but relevant.
Not that there aren’t more to consider.
I trust that you’re developing your
caregiver critical thinking muscle,
so be on the lookout for more.
Use the Discharge plan worksheet to track your due diligence.
If you need help, reach out
A few tips based on my experience:
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Collect contacts
Make sure you have the contact names and numbers for their care team; inclusive of social worker or discharge planner, director of therapy (if receiving therapy), director of nursing, attending physician...
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Be present
Mottos:
Can’t hurt to ask.
Ask until it makes sense.Make your presence known when you visit and ask question. I have come across countless non-medically trained caregivers asking excellent questions; just a matter of being engaged. This also keeps the medical team on their toes because they know you are an engaged member of the team too!
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Attend therapy
Attend therapy sessions to
1. Witness your loved-one’s mobility
2. Witness what it takes to safely move your loved-one
3. Reality check for you and your loved (can you and they manage at home? What is the appropriate setting?)
4. Inform facility team, what home looks like and their level of function. Remember what you learned from Chapter 1? Are there stairs in and outside the home? Can the rooms, hallways and door ways accommodate a wheelchair? If they can’t manage the stairs, is this temporary or long-term? Can they remain on the first level? Is there a bathroom on the main level to accommodate their hygiene and toileting needs? Is there another setting they can temporarily go to, are there able & available caregivers to safely manage their care, and more…These are just a few ideas to inspire your creativity to guide the care team to best suit their needs towards a safe discharge.
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Monitor progress
Now the plan is that they will improve and get stronger throughout their stay yet the opposite may happen.
Things often fluctuate or stay the same.
FYI: in a skilled setting (there’s that word again), insurance pays for progress and they don’t like when things get worse (more money).
If your loved-one is either not improving or regressing someone needs to
1. tell you why (eg. maybe a UTI …) and
2. tell you how they’re going to fix it.
I must mention that there are times when a patient may not improve and there’s not much, if anything, that can be done. As we age we may not have the same “bounce-back”.
Often a decline medically or in function is the new normal and we have to adjust around that. -
DC mindset ASAP
If in a rehab facility, encourage your loved one to do their best.
Often patients think they have a lot more time than they actually do and waste days that otherwise could’ve been very productive.
Insurance companies often use algorithms to predict discharge dates and try to stick to authorizing within that timeframe, despite when patients started to get serious about therapy.
Which leads to… -
Anticipated DC date?
Know the timeframe the insurance company is covering.
Usually shortly after admission the facility has an expected date of discharge they should share with you.
That date is not written in stone. There are multiple factors that may change that date; hence your staying involved and engaged. -
Appeal?
The more clarity you have, the better you can advocate for your loved-one. Before discharging patients, with Medicare and some other insurances, they have to give notice (usually at least 48 hours before the planned DC date) and provide the opportunity and contact information of who to call if you want to appeal.
Now you must make contact within a certain timeframe. So if you plan to appeal, call as soon as possible.
I know that’s a lot.
But trust me, it’s worth it.
Here’s why
Importance of
Discharge Planning
Continuity of care:
Making sure care continues until all’s well. For example: medications, wound care, therapy, nursing… Gaps in care and treatment can land them right back in the hospital. Speaking of which…
Reduced chance of readmission:
Before you leave the hospital you want to make sure you have the necessary resources, support, supplies and follow-up care in place to manage their health conditions effectively after leaving the hospital.
Safety:
What is the safest setting after discharge? Home alone, home with certain services in place/home amendments, with family, rehab, nursing facility, assisted living facility… Can they manage their medical regimen, medications, treatments… Thorough discharge planning minimizes risk of unsafe discharges.
FYI
Safety discharge concerns alone will buy you but so much time. Generally speaking, once a skill starts to “plateau”/becomes chronic the insurance will not just pay for safety alone. Start generating a safety plan ASAP.
Patient Empowerment:
Empowers active participation, ability to make informed decisions about their health and advocate for their own health needs.
Again totally worth
the effort and advocacy!
When Home Discharge Isn't Safe
Alternative Discharge Options
Skilled nursing facility: For continued medical care and therapy before returning home.
Rehabilitation facility: Focused on regaining function and independence.
Long-term care facility: When return home isn't realistic given current care needs.
Assisted living with memory care: For those needing supervision but not skilled medical care.
Advocating for Appropriate Placement
Your role: Ensure discharge destination matches actual care needs, not just family wishes or insurance pressure.
Questions to ask:
Does this placement provide adequate supervision for their cognitive state?
Can they manage the level of independence this setting requires?
Will this setting support their path toward maximum possible recovery?
To Do
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Schedule to meet with the team. If in the hospital, find out the time for medical rounds. That's when the team circulates to each patient's room and discuss their care. Be there at that time. Really helps to make sure all are on the same page and can address your questions and concerns.
If in a skilled nursing facility/rehab, schedule a meeting with the team; usually includes nursing, therapy, social worker/discharge planner. The latter are a very important to coordinate discharge (DC) needs.
Meet multiple times to stay on top of progress and barriers. The very beginning, right before DC and a few in between.
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Make notes on your worksheet
Resources
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Glossary of relevant terms and definitions. A useful tool to equip you along your caregiver journeycare insurance
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May come in handy if given the option to pick a provider for continuity of care after discharge.
Previously shared link comparing different provider services, such as home care, nursing facilities...
But first, make sure insurance company will pay (in/out of network status and authorization approved...). Social worker, discharge planner or billing office will assist with this.
Now You Know:
The relevance of starting discharge planning as soon as your loved-one is admitted
Important factors to consider prior to discharge
Steps to advocate for your loved one