Health & Fitness

Ask Nancy: A discharge plan is critical for an elder person leaving hospital or rehab

Q. My mother, age 78, had a stroke three weeks ago. She was recently transferred to a rehabilitation center, where she will stay two to three weeks. Her doctors are confident that she will be able to resume a fairly active and independent lifestyle.

I’m prepared to get everything all set for my mother’s return to her home and fortunately, I have friends who have been in similar caregiving situations and they are giving me lots of advice. But I don’t know where or how to start getting things in order. Can you give me a list of what to do?

Julie R.

A. A lot of what you need to know will be included in a personalized discharge plan that the hospital or rehabilitation center prepares for patients and their caregivers when they’re ready to return home. Its purpose is to ensure that the patient is able to safely continue their physical improvement in their own residence, thus reducing the possibility of a hospital readmission.

A discharge plan will include the type of care and services that will be required at home — from help with personal care and meal preparation to home physical therapy; a list of medications your mother takes with specific instructions on how to take them; and, generally, a list of resources such as transport services and home health agencies that serve your mother’s area. It is finalized just before your mother’s discharge so it will take into account her progress through the last day.

Olga Manrique, director of the Social Work and Care Management Department at Baptist Hospital in Miami, explained how crucial your involvement will be to your mother’s recovery.

“A family’s willingness and ability to support their loved one in these situations makes the difference between good and poor outcomes,” she said. “It begins with meeting with the treatment team, discussing mutual expectations and goals of care, and making sure the family understands what’s involved so that they can support their loved one in complying with the plan.”

Manrique offered some specific examples of how you can begin to implement your mother's post-rehabilitation care plan at home:

▪ Prepare the home environment and ensure adequate supervision is available.

▪ Schedule necessary follow-up appointments with the patient’s physicians prior to discharge.

▪ Determine a plan for transportation to physician appointments.

▪ Make sure that you or professional caregivers you hire understand your mother’s medication requirements and that her nutritional and medical needs are properly met.

On your mother’s discharge day, allow plenty of time to review the discharge instructions with the nurse to make certain that you understand what needs to be done.

Here’s a link to a discharge planning work sheet from Medicare. I recommend reviewing it before you meet with the care manager so that you are prepared with questions and your concerns are addressed: http://www.medicare.gov/pubs/pdf/11376.pdf.

Your mother is fortunate to have your support and involvement in her recovery.

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