This was the frantic call I received from a daughter this past Friday. The hospital was discharging her 90 year old mother but had omitted to confirm that services and follow up medical appointments were in place. Now in many cases, this might not be a problem- depending on the health of the patient. But in this particular case, her mom had high care needs and in addition to 24 hour private pay care (that was in place), public supports including nursing and dietary services were also required. Her mom was returning home after being treated for pneumonia. Prior to this admission she had been home for less than one week, after having spent several months as an inpatient following a severe stroke. She remained immobile and was on a feeding tube.
On this late Friday afternoon, she was sent home with a requisition for blood work to be done the next day; however it was not arranged to be done at her home. She was also sent home with new medications that had to be administered by a feeding tube, yet the community nurse (from the LHIN) was not yet in place. Even with the use of a hoyer (mechanical) lifting device, she required 2 people to transfer her and her 90 something year old husband was not physically able assist the private PSW.
What are families to do who find themselves in this unfortunate situation?
When things are complicated, my advice is not to be discharged home on a Friday and never before a long weekend. If unavoidable, request a discharge meeting so that all team members can provide their recommendations and that any required referrals can be arranged with assurances that the gears are in motion. This is the opportunity for family to ask questions and raise any concerns that they may have. If you are fortunate to have extended family, have one person assigned as the key contact. In many cases with seniors who are in poor health, there simply is no room for error.
In the above situation, this family was fortunate as they were able to get us involved; we made the necessary calls at 7:00 pm on a Friday night to ensure that a nurse was coming to provide the night time medications. This should not have been necessary. For the majority of families that are on their own it really is important to push back, ask questions and sometimes ‘no thank you’ is the right answer.