"According to Medicare, discharge planning is a process that determines the kind of care a patient needs after leaving the hospital. Discharge plans should ensure a patient’s transition from the hospital to another medical facility or to their home is as safe and smooth as possible"

HOSPITAL DISCHARGE 

Whenever there's a medical discharge in progress there should be a Discharge Planning at home.

What Is Discharge Planning?

According to Medicare, discharge planning is a process that determines the kind of care a patient needs after leaving the hospital. Discharge plans should ensure a patient’s transition from the hospital to another medical facility or to their home is as safe and smooth as possible.

Only a physician can authorize a patientʼs release from the hospital, but the actual process and preparation of discharge planning can be completed by a number of people. Some hospitals have a dedicated discharge planning manager on staff, but your point person could also be a social worker, nurse, or other hospital representative. Ideally, and especially for the complicated medical conditions, discharge planning is done with a team approach.

In general, the basics of a discharge plan are:

• Evaluation of the patient by qualified personnel
• Discussion with the patient and/or their representative and involving them in the planning
• Reconciling medications – a thorough review of prescriptions, plus comparing pre-hospitalization meds with post-discharge meds to be certain there are no duplications, omissions, harmful side effects, or drug interactions.
• Planning for homecoming or transfer to another care facility
• Determining the need for caregiver training or any other support
• Referrals to a home care agency and/or appropriate support organizations in the community
• Arranging for follow-up appointments or tests
• Who to contact if you need help – ensuring you have the name and email address of your go-to person for care questions, as well as a phone number where you can get help 24 hours a day, including weekends.

The planning discussion will cover everything from the types of care that will be required to equipment needs, from diet and meal planning to medication administration. Even transportation and chores should be covered.

Why Is Good Discharge Planning So Important?

The main reason discharge planning is such a priority – not just for hospitals and care teams, but also the U.S. Centers for Medicare and Medicaid Services – is this:

Effective discharge planning can decrease the chances the person you care for is readmitted to the hospital.

A thoughtfully developed plan aids recovery, ensures medications are prescribed, and given correctly, and adequately prepares you to take over your friend or family member’s care – all of which contribute to care that reduces the chance of readmissions.

The Caregiver’s Role in the Discharge Process

The discharge planner will look to you, the caregiver, for history and insights about your friend or family member. As their advocate, you are likely to play a central role, managing many vital tasks:

• collect information
• speak to doctors
• transport the patient
• ensure lab tests are done
• pick up, prepare and give medications
• research treatment options and risks
• handle insurance

As discharge nears, things can feel rushed at the hospital; in that rush, it can be easy to forget what needs to be discussed. If you’re feeling hurried, it is reasonable to ask the discharge planning team to slow things down so nothing is overlooked.

You may want to print out and bring this fact sheet with you to the hospital; if for some reason the discharge planning team doesn’t cover these subjects, you should feel comfortable raising them, yourself.

Discharge to home: Finding the help you need

Listed below are common care responsibilities you may be handling for your friend or family member after they return home:

• Personal care: bathing, eating, dressing, toileting
• Household care: cooking, cleaning, laundry, shopping
• Health care: medication management, physicianʼs appointments, physical therapy, wound treatment, injections, medical equipment and techniques
• Emotional care: companionship, meaningful activities, conversation

There is no single best path for lining up the help you will need. Patients and caregivers turn to many different sources for support

Do you need Hospital Discharge Services?

We will come to your home to get to know you better. After we have more information, our caregivers can create a custom care plan according to you and your loved one needs of care.

Our Hospital Discharge Services included:

• Discharge Planning
• Nurse Case Management
• Transportation Prearrangement
• Home Healthcare Services
• Home Care Services
• Personal Care
• Respite Care Services
• Medical Translation Services
• Companion Care Services
• Stroke Recovery Care
• Wound Care
• Chore Services
• Durable Medical Equipment
• And other servicesas well

If you or your loved one needs Hospital Discharge Service, get in touch with Evolve Community Services. We will send a case manager to your home. During the consultation, the case manager will ask questions to better understand you and the services you need. We are will assist you with the hospital discharge process and we will be able to personalize the home care services you receive after the discharge. More than anything, we want you to stay home safe, and avoid an unnecessary return to the hospital. 

Ready to Get Started? Contact us and learn more about our services.