Hospital Discharge Planning: A Guide for Families and Caregivers
A trip to the hospital can be an intimidating event for patients and event for patients and their families. As a caregiver, you are focused completely on your family member’s medical treatment, and so is the hospital staff. You might not be giving much thought to what happens when you relative leaves the hospital.
Yet, the way this transition is handled – whether the discharge is to home, a rehabilitation (“rehab”) facility, or a nursing home – is critical to the health and well-being of your loved one. Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care.
Patients, family caregivers and healthcare providers all play roles in maintaining a patient’s health after discharge. And although it’s a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system.
This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one. If you are a caregiver, you play an essential role in this discharge process; you are the advocate for the patient and for yourself.
What is discharge planning?
Discharge planning is “A process used to decide what a patient needs for a smooth move from one level of care to another”. Only a doctor can authorise a patient’s release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager or other person. Ideally, and especially for the most complicated medical conditions; discharge planning is done with a team approach.
In general, the basics of a discharge plan are:
The discussion needs to include the physical condition of your family member both before and after hospitalisation; details of the types of care that will be needed and whether discharge will be a facility or home.
It also should include information on whether the patient’s condition is likely to improve, what activities he or she might need help with, information on medications and diet, what extra equipment might be needed, such as a wheelchair, commode, oxygen; who will handle a meal preparation, transportation and chores and possibly referral to home care services.
Why is good discharge planning important?
Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, help in recovery, ensure medications are prescribed and given correctly and adequately prepare you to take over your loved one’s care.
Not all hospitals are successful in this. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good after care release.
Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving hospital and 18 percent of patients discharged from hospital are readmitted within 30 days. This is not good for patient, not good for the hospital and not good for the financing agency. On the other hand, research has shown that excellent planning and good follow-up can improve patient’s health, reduce readmissions and decrease healthcare costs.
Even simple measures help immensely. For example, you should have a telephone number(s) accessible 24 hours a day including weekends, for care information. A follow-up appointment to see the doctor should be arranged before your loved one leaves the hospital. Since errors with medications are frequent and potentially dangerous, a thorough review of all medications should be an essential part of discharge planning. Medications need to be “reconciled”, that is, the pre-hospitalisation medications compared with post-discharge list to see that there are no duplications, omissions or harmful side effects.
Under the best circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital.
The caregiver’s role in the discharge process
The discharge staff will not be familiar with all aspects of your relative’s situation. As caregiver, you are the “expert” in your loved one’s history. While you may not be a medical expert, if you’ve been a caregiver for a long time, you certainly know a lot about the patient and about your own abilities to provide care and a safe home setting.
The discharge planners should discuss with you your willingness and ability to provide care. You may have a physical, financial or other limitations that affect your caregiving capabilities. You may have other obligations such as a job or childcare that impact the time you have available. It is extremely important to tell the hospital staff about those limitations.
Some of the care your loved one needs might be quite complicated. It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator or transferring someone from a bed to a chair.
If your loved one has memory problems caused by acquired brain injury, stroke, or another disorder; discharge planning becomes more complicated and you will need to be part of all discharge discussions. You may need to remind the staff about special care and communication techniques needed for your loved one. Even without impaired memory, people often have hearing or vision problems or are disorientated when they are in hospital so these conversations are difficult to comprehend. They need our help.
If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge. Written materials must be provided in your language as well. Studies have shown that numerous, and sometimes dangerous errors can be made in home care when language is not taken into account at discharge.
Because people are in a hurry to leave the hospital or facility, it’s easy to forget what to ask. We suggest you keep the questions on pages 5-6 with you, and request that the discharge planner take time to review them with you.
Getting help at home
Listed below are common care responsibilities you may be handling for your family member after he or she returns home:
There are organisations that can help with services such as transportation, meals, support groups, counselling and possibly a break from your care responsibilities to allow you to rest and take care of yourself. Finding those services can take some time and several phone calls. The discharge planner should be familiar with the community support that is available, but if not, contact us to discuss your needs to see how we can help. Family and friends also might assist you with home care.
If you need to hire paid in-home help, you have some decisions to make. Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. You might be handed a list of agencies, with instructions to decide which to use – but often without further information. This is another good reason discharge planning should start early – as caregiver, you will have time to research your options, while your loved one is cared for in hospital.
Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background.
You may have a choice between hiring an individual directly or going through a home care or home health care agency. Part of that decision may be affected by whether the help will be “medically necessary”. i.e. prescribed by the doctor, and therefore paid for by the NHS or other insurance. In that case, the funder will most likely determine the agency you use.
Discharge to a facility
If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patient’s health and capabilities, review medications and help you select the facility to which your loved one is to be released.
Too often, however, choosing a facility can be a source of stress for families. You may have very little time and little information on which to base your decision. You might simply be given a list of facilities and asked to choose one. To help you, a social worker can offer much needed advice and support.
Convenience is a factor – you need to be able to easily get to the facility – but the quality of care is very important, and you may have to sacrifice your convenience for the sake of better care. The list of questions on pages 5-6 will give you direction as you start your search for a facility.
Paying for care after discharge
You might not be aware the NHS does not pay for all services after a patient has been discharged from the hospital. However, if something is determined by the doctor to be “medically necessary” you may be able to get coverage for certain skilled care or equipment. You will need to check directly with the hospital, to find out what might be covered and what you will have to pay for. Keep careful records of your conversations.
What if you feel its’s too early for discharge?
If you don’t agree that your loved one is ready for discharge, you have the right to appeal the decision. Your first step is to talk with the physician and discharge planner and express your reservations. The hospital staff will provide you with details of appeals process. If that isn’t enough, you will need to contact someone who can advocate for your needs.
Improving the system
The discharge planning process varies from hospital to hospital. Who does it, when it’s done, how it’s done, what kind of follow-up is mandated and whether caregivers are assessed for their ability to provide care and included as respected members of the discussion are all elements that differ from setting to setting.
In general, hospitals are funded when beds are occupied. Despite its benefits, which clearly increase the wellbeing of the patients and caregivers, discharge/transition planning is often not given the attention it deserves, and indeed, ineffectual planning often serves to add to patients and caregivers’ stress.
Some Basic Questions for Caregivers to Ask
3. Questions when my relative is being discharged from home:
5. Questions when discharge is to a rehab is a rehab facility or nursing home:
6. For longer stays:
7. Questions about medications:
9. Questions about finding help in the community:
"We are medical practitioners. The real experts are the parents. Over the last 35 years they have taught me everything I know"
"When different organisations assess different aspects of a child's neuro-rehabilitation needs, everyone looks at things from a different perspective and have conflicting priorities"
"Different 'experts' involved in paediatric neuro-rehabilitation come from different organisational cultures which causes conflict and has a negative effect on the outcomes for the child."
"Taking brain injured children home causes high stress for families. Disjointed services exacerbate family stress levels."
"Case management for children and young people post acquired brain injury is 'pivotal' to successful outcomes and must be local"
"Often families don't have the financial capability to access services. We need to rethink how we deliver neuro-rehab services to children and young people"
"Rehabilitation interventions can lead to positive outcomes for children and their families if delivered in the familiar home environment and applied to everyday situations"
"Too often children and young people with ABI are discharged from hospital without specialist brain support that they and their families need to overcome lifelong challenges"
"Brain development is complex and prolonged. Brain plasticity is influenced by a range of factors. Plasticity provides a base for neuro-rehab therapies and treatment"