If you have a relative about to go into or be discharged from hospital, you should know that the experience is much different today from the way it used to be. Whereas care used to be mostly physician directed, today much of the decision making and planning, including discharge, are done mostly by a medical team, consisting of nursing, social work, physiotherapy, occupational therapy, dietitian, and perhaps others.
Discharge planning starts almost upon admission. For some planned hospitalizations, it starts even earlier during pre-admission assessments. Basic information the team will need to know includes the patient’s current living situation, ability to do personal care, and names and contact information of family or other supports.
As soon as possible after a hospital admission, family members should find out what the diagnosis is, the anticipated treatment, the expected results, and if ongoing daily functioning is expected to change. Family members should also find out as soon as possible what the expectations are for discharge. What criteria will the team decide when your loved one is ready to be discharged? Make sure you let the Social Worker know you would like to be involved in any issues surrounding discharge planning.
On occasion, a discharge may occur rapidly following an evaluation by the physician in charge. These “expedited” discharges may be decided on the same day as the discharge will happen. Family members (as well as team members sometimes) can be caught unaware. The result can be that appropriate community services may not have been set up and concerns may “fall through the cracks,” putting your relative at risk.
Hospital units have “rounds,” usually at least weekly when all of the current patients’ conditions and progress are discussed. That is where discharge discussions and planning often occur. Find out when rounds take place on your relative’s unit, and keep abreast of what was discussed in them.
During the course of hospitalization, there may be family meetings to discuss your relative’s progress. If there hasn’t been one and you think it would be helpful, ask for it. Before discharge, there should be a specific discharge planning conference with the family. Included in this will be the relevant medical team members and maybe a representative from the community services team described below. In fact, this meeting may end up as a discharge information conference as opposed to a planning meeting, because it has already been decided that someone is going to be discharged.
If, after discharge, a patient will need community based services such as physiotherapy, occupational therapy, home support services, Nursing Home (what is now called in BC, Complex Care), or a rehabilitation unit, the medical team may refer the patient to a separate community services team (in Vancouver Coastal Health Region it is called the Transitional Services Team). Someone from this team will do a comprehensive assessment by talking to the medical team and reading the patient’s chart. They will use predetermined guidelines to help evaluate what community services the patient is eligible for, and initiate the referral to those services. Their mandate is also to follow up and make sure that the needed referrals have, in fact been set up.
Support services in the community are provided through community health units. Before discharge, you should receive information about what services have been arranged and a phone number to contact the provider in case there are questions. At some point, your relative will be assigned a Case Manager at the Health Unit who will be responsible for the provision, increase, or decrease of the services. They will arrange for a home visit usually in the couple weeks after discharge.
Family members’ views on the readiness of their relative for discharge and the services which will be needed may differ from those of the professional teams. Be aware that being discharged from hospital does not imply that one is in good health, independent and no longer sick. It means that he or she no longer requires daily medical attention, care, and monitoring by professional hospital staff. Discharge does not necessarily mean one is able to resume their daily activities at the same level as before hospitalization.
If you question the timing of discharge, or level of services which will be provided, speak to the Nurse in charge, or the Social Worker. Be very clear about why you feel that your relative is not ready to be discharged. Make sure that they have a clear understanding of functioning ability before hospitalizaiton. Remember that community resources are limited. The guidelines for help with personal care in the home are quite restrictive. It is impossible for the team or community services to assume all responsibility for the safety and care of your relative post discharge. You may be able to talk with someone from the Transitional Services Team mentioned above if you have concerns.
If you feel your relative would benefit from a rehabilitation facility (for example, in Vancouver there is Holy Family Hospital) be aware that there are criteria for admission to these units and that the space is limited. The ultimate decision for admission may come not from the team treating your loved one, but from an admissions person or team at the rehabilitation unit.
Many family members take time off from work, or fly out from long distance to be with their relative while the latter is in hospital. It might make more sense to arrange time off for your visit for when your relative is about to be discharged, so you can help them at home. If you cannot stay, prepare meals ahead of time and freeze them, tidy up the home, make sure there are not hazards that might lead to a fall.
(Diamond Geriatrics wishes to acknowledge the time and information received in writing this newsletter article from Social Work and Transitional Services Team staff at St. Paul’s Hospital in Vancouver, BC. All inaccuracies or mistakes are strictly ours.)
Transfers from Hospital To Nursing Homes
While waiting for admission to a nursing home from hospital your relative may be transferred to another unit within the hospital or somewhere else. Sometimes called Transitional Care Units, these units are for patients who are considered “stable and no longer needing acute care.” They have less staffing than acute care/medical wards in the other parts of hospitals. They often have some rehabilitation activities, but they are not considered true rehabilitation facilities.
Family members should find out what services are available in the unit. If you feel that your relative would benefit from additional help, you may be able to bring in someone privately. Private help may include companions for social stimulation and recreation or physiotherapy and occupational therapy. It is important to keep your relative as active as possible so that they do not lose functioning ability.
Nursing Home placement in British Columbia and most provinces is on a “first bed available” basis. You will be given a list of some names of places and you can designate your preference, but there is a good chance you will first have to accept placement wherever a space becomes available if it is considered appropriate to needs. When that space is available, you may have very little time, only a day or two until the transfer happens. In some cases, family members have had no time to go and see the facility before discharge.
To learn more about getting the best care possible in Nursing Homes, read “Nursing Homes and Assisted Living,” the second edition of “Nursing Homes: the Family’s Journey,” appearing next month.
Warning! Don’t Let Information Get Lost!
When a client of ours was discharged to a care facility it took the care facility three days to find out the woman was a brittle diabetic. Why? Because the information was not included in the transfer information sent by the hospital, and she had a new doctor on admission. Other clients have been discharged with papers saying they had conditions which they did not have.
It is easy for information to get lost or mis-transcribed upon discharge. Make sure that wherever your relative is going the correct information goes with them. Make sure the doctor, pharmacy, or care facility has the right diagnoses and the correct medications and when they are to be taken. Verify what you know from your relative’s past, with what is down on paper or sent electronically. If there are medications with which you are unfamiliar, find out what they are and why they were prescribed.
Also make sure that you or your relative know the costs of the medications that are prescribed on discharge. In hospital, they will be covered; in the community, or in a care facility, they may not be, and the costs could be very high. If you will have to pay for them, check to see if a cheaper generic version is available and whether it would be appropriate.
Tip for Families
When you have a relative in hospital, divide up the responsibilities.
Appoint one family member to:
- be the contact with the hospital staff for communication. That will help to reduce miscommunication among family members.
- to deal with friends and others.
- to get the house ready for the discharge.
- To take care of bills and other payments.
