Discharge Planning from the Hospital

Frequently an unanticipated  hospitalization is the trigger of a crisis. Families suddenly realize that their loved one can no longer live independently, or that one parent can no longer provide the care that the other parent needs. After assessing the needs of the patient, EldercareNY works with doctors, discharge planners, and hospital staff, often buying valuable time so that care at home can be arranged.

"I can help advocate for discharge planning to be done properly by seeing to it that the hospital does what it is supposed to do prior to sending the person home."

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"They tell me Dad is being discharged home from the hospital tomorrow. Well I don’t quite understand this; he’s 82 years old, he fell at home, he’s totally confused, he can’t walk without help; they say he’s too confused to go to rehab; they say he can go to a nursing home, but that Medicare won’t pay for it again because he’s too confused. He is confused, but is that his fault? Frankly, this is all quite sudden, and I’m just not ready to put him in a nursing home, and who can afford to pay $300/day for a nursing home anyway. There must be some other option, some service that can guide someone in my predicament."

Managing Transitions: Years of Experience

Experience has shown me that even highly educated, high-functioning families need at least a two-hour consultation to help them get a grasp of what lies ahead following their loved one’s hospitalization and to put the necessary pieces in place. Hospital social workers and nurses do not have two hours to give each patient that needs home care set up by the time they return home. They do not get involved in helping you hire a home health care attendant other than to give you a list of agencies to call.

To further confuse you, they may make a referral to a certified home health agency and tell you that Medicare will pay for an aide "for 4 hours/5 days a week." This only serves to complicate the issue if your mother needs at least eight hours of help a day -- if not 24 hour care at home. My preference is to interview aides prior to discharge and have them start in the hospital to see how they work out before your family member is discharged from the hospital. It reduces everyone’s anxiety a great deal.

Often the hospital neglects to provide physical therapy to get the person back on their feet, which in turn would reduce the need for home care. I can help advocate for discharge planning to be done properly by seeing to it that the hospital does what it is supposed to do prior to sending the person home,  which often results in preventing a rehospitalization. Sometimes in the course of the physical therapy the conclusion is reached that a short stay in a rehabilitation facility would be beneficial, and this is covered by Medicare. Please see "Paying for Care" for further discussion about how care can be covered at home.


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