Increasingly, families are struggling with hospital discharges, especially for elderly persons with complex care needs. The primary reason is that transition planning is not sufficiently planned for or considered. Before you agree to any discharge for a family member, you must first understand what a high-quality transition plan looks like. In a previous blog post, Families Struggling with Hospital Discharges, we outlined the Ontario Health quality standards for discharge planning. To follow up, here is an easy framework for families to use when faced with this situation.

Document In-Hospital Care for Easier Transition to Discharge Planning

Hospitals can be an anxiety-producing environment for patients and their families, which affects their understanding of the hospital environment and the language used in healthcare and in discharge planning. Improve your understanding and recall by taking up one or more of the following suggestions. Doing so will provide a trusted source of information and facilitate communication among all individuals involved in the discharged patient’s transition plan and caregiving at home.

1. Bring a family member or friend who listens carefully, thinks clearly, and isn’t afraid to ask questions. They can document discussions and decisions without the anxiety you may be feeling.
2. Bring a notebook to document everything and everyone for review or referral later.
3. Write down the names and healthcare roles of the people involved with the patient. It’s hard to remember the name of a specialist doctor after you have seen five or six doctors in one morning.
4. From the moment your family members enter the hospital, begin planning their discharge. You don’t want your loved one to stay in the hospital any longer than necessary; they don’t want you to be there either!

Transition Planning Basics

This is a basic plan. Write it down in the patient’s care notebook, the one discussed in the last section. Refer to the transition plan often. A transition plan takes time, so talk to hospital staff early about your goals for their care at home.

1. Care Goals

What are the goals of care at home? An example goal is to aggressively rehabilitate the patient so they can walk and enjoy life.

2. Daily Schedule

Sketch out a daily schedule to plan for care needs. For example, what is the morning routine? How are incontinence brief changes handled? Are they exercising daily, and if so, how? When and how can they get up safely in a chair, take short walks, or handle meals?

3. Medical Coordination

Who will be the physician coordinating care? Is it your family doctor? Does he or she know about the hospital stay and goals of care?

4. Medication Ordering and Administration

Make sure all medications are ordered at the community pharmacy and picked up in advance of discharge. Who will administer the medications at home?

There could be more than 10 different medications being administered at other times. Is the partner or spouse able to do this, or will they require help?

5. Health Care Providers Required

Determine what provider support is needed in the home. For example, a wound care nurse from Ontario Health at Home (OHAH), a private physical therapist to address mobility, a Personal Support Worker (PSW), and an RPN or RN to supervise narcotic medications.

Some of the providers may be obtained through a care coordinator with OHAH, and others may be procured through private agencies. Determining care goals in advance and then matching providers and determining the costs for private care is a critical step before discharge.

6. Medical Equipment Required

Depending on the care needs, there may be substantial equipment required in the home. For example, a hospital bed with a special mattress to support skin integrity, linens, a bedside commode, a Hoyer lift with slings, a wheelchair, a walker, a chairlift for stairs, etc.

Equipment may be rented or purchased depending on the situation. It’s wise to check extended health care benefits with insurance policies to determine what personnel and equipment are covered. Be sure to work with reliable and well-regarded equipment companies who will set up the equipment for you in advance and service the equipment on site. Not every company will do this.

7. Emergency Plan

If you are caring for a very ill person at home, it’s wise to have a written emergency plan handy where caregivers and others can read it. If you, as the spouse, suddenly become ill, who should be called? List the key names and numbers of caregivers, their supervisors, and schedules in the home. List the physician who is coordinating care. And who are the family members to call in an emergency – names and numbers.

Using the framework above will help you plan a hospital discharge well in advance. There are many things to consider, and you want to be sure that your loved one has a well-planned, safe, and easy transition from hospital to home. Talk to the hospital staff and advocate early to understand what will be needed. If you are not ready or concerned that the discharge is too early, then say so. An unsafe discharge is in no one’s interest.