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Aging Wisely February, 2011 | Aging Wisely

Hospital Discharge: Checklist for Families

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Our previous blog posts have covered the Challenges of Hospital Discharge for Elders and Ways You Can Help an Aging Loved One Have a Safe Hospital Discharge. Now we will share some important questions you should ask (a checklist of sorts) in the hospital discharge process.

Did I get written discharge instructions explained to me with time to ask questions and clarify any concerns? Items that should be included:

o Reason for admission, procedures done, outcome
o Do we know who to contact if we have a problem after discharge?
o What symptoms should we be watching for and what do we do if we have a concern?
o Medication list (and how will I make sure all my doctors & providers are updated with the new list)
o Follow up appointments

Get information about follow up treatment and therapy that might be essential to recuperation. Find out:

o Will I be receiving therapy services at home, inpatient or outpatient? You will need to select a provider and the hospital will generally provide a list of options if you ask, but you should do your research so that you can make an educated choice. There is information online about provider outcomes and you may wish to check with your loved one’s doctor or geriatric care manager for recommendations.
o Does insurance cover these services (your insurance may impact the choice of provider)?
o How long can they be expected to last? What outcome is expected? (Share your goals and concerns as well.)

Find out about the patient’s home care needs and what assistance may be needed in the weeks following the hospitalization. Issues to consider:

o Patient’s functional status: strength, ability to transfer safely, bathing, dressing, weakness, physical limitations.
o Household needs: can the patient take care of the household? Do laundry, clean? Help preparing meals (in compliance with nutritional needs/medical orders)?
o Transportation: will the patient need rides to appointments or help with errands?
o Medication management: consider how the patient will get new medications and discard old ones properly, manage following a new medication routine, communicate changes to all doctors/providers?

*Most times, if a patient is returning home after a hospital stay, they will receive some Skilled Home Care services, covered under Medicare or insurance. These services often do not begin on the day of discharge and are not intended to cover custodial needs such as most of those listed above. Medicare may cover support from a home health aide, but only as long as the patient requires skilled services such as physical therapy or a R.N. (for example for dressing changes/wound care). If you have concerns about any of the areas above, you should talk to a licensed, private duty home care provider, such as our sister company EasyLiving, about affordable home care and transitional packages to fill any gaps.

Ensure the home environment will accommodate post-hospital needs:

o Is any special medical equipment needed? Have arrangements been made? Will equipment be delivered and when? Do I need to pick up equipment and where can I do so? Cost/insurance coverage?
o How safe is the home environment? Have we completed a home safety, falls prevention assessment?
o Does the patient have a Personal Emergency Response System in case he/she falls or needs to call for help?

If you would like professional advice on how to prepare for a hospital discharge, what resources are available and how to get the best after-care, Aging Wisely’s geriatric care managers provide caregiver consultations, in-hospital and home safety assessments and patient advocacy.

Our professional patient advocates are here to help-contact us today!

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Help for Caregivers: Hospital Discharge Checklist

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Our previous blog posts have covered the Challenges of Hospital Discharge for Elders and Ways You Can Help an Aging Loved One Have a Safe Hospital Discharge. Now we will share some important questions you should ask in the hospital discharge process.

download-discharge-planning-checklist

Did I get written discharge instructions  explained to me with time to ask questions and clarify any concerns? It is essential that both patient and a primary caregiver understand the discharge instructions as well as the recovery plan and have a chance to understand any questions.

Get information about follow up treatment and therapy that might be essential to recuperation.  There are different options for physical therapy and other services needed after a hospitalization.  Sometimes a patient would prefer to return home immediately, but may benefit more from more intensive inpatient rehabilitation.  There are also hospital-based rehab. programs which count differently to insurance, which can thus allow more coverage for conditions requiring longer therapy and recuperation.

Find out about the patient’s home care needs and what assistance may be needed in the weeks following the hospitalization.  It is essential to have a picture of what the patient’s needs might be and therefore what additional supports may be needed while recovering (this is true whether returning home or even to an assisted living facility, as needs may be different than before).  This includes reviewing the environmental safety for accomodations and falls preventions measures.


*Most times, if a patient is returning home after a hospital stay, they will receive some Skilled Home Care services, covered under Medicare or insurance.  These services often do not begin on the day of discharge and are not intended to cover custodial needs such as most of those listed above.  Medicare may cover support from a home health aide, but only as long as the patient requires skilled services such as physical therapy or a R.N. (for example for dressing changes/wound care).  If you have concerns about any of the areas above, you should talk to a licensed, private duty home care provider, such as our sister company EasyLiving, about affordable home care and transitional packages to fill any gaps.

If you would like professional advice on how to prepare for a hospital discharge, what resources are available and how to get the best after-care, Aging Wisely’s geriatric care managers provide caregiver consultations, in-hospital and home safety assessments and patient advocacy.

get-help-from-our-patient-advocates

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What Can You Do To Ensure a Safe Hospital Discharge for Elderly Loved Ones?

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As our previous blog post points out, the hospital discharge process is a key transition time. Without proper support and resources as well as good understanding of follow up instructions, many individuals will return to the hospital for reasons that could have been avoided. No one wants this, and it can be especially dangerous for elders and persons with chronic conditions.

If you are a family caregiver and an elderly loved one is hospitalized what can you do to ensure a safe transition after the hospital stay?

Consider the discharge process as beginning at the start of the hospital stay. Find out who is responsible for discharge planning and introduce yourself, explaining that you will be involved and giving relevant information about the patient’s living situation, supports and concerns. Discharge may not seem like a top concern at the beginning of a hospital stay, but with shorter hospital stay lengths, good groundwork starts as soon as possible.

Keep good records. An online personal medical record system is an ideal way to manage your loved one’s health history, medications, and store key contacts so this information can be readily available. You can also use a notebook or file to store the information, as long as you have it available and provide good information to new providers. Make sure you communicate information that is vital to your loved one’s health, such as medications that really should not be changed or typical complications or concerns that arise during hospitalization or procedures.

Get to know the medical staff and check in about what is going on throughout the stay. Ask questions (and keep records as per above) about procedures, tests, expected outcomes, medications.

Understand that you or a designated patient advocate will need to take charge in being the centralized hub of information. This includes ensuring you understand instructions, what will happen after discharge, and the functional status of the person (and therefore what support might be needed). Ask questions and anticipate concerns that might arise and do not hesitate to voice them.

Consider using a professional patient advocate for consulting or assessment during this process. Aging Wisely’s Care Managers know the discharge process, use a systematic approach and can help families anticipate needs and find resources to help. If you are caregiving from a distance, this support is vital as it is very difficult to manage the discharge process from afar.

Plan for the immediate transition time. The first day or two after discharge can be particularly problematic. Think about practical issues such as getting new medications, food and personal items while needing to attend to a person in a weakened state. Will you be able to help the patient from bed to bathroom? Services such as Medicare home health care and medical equipment rarely arrive immediately and are not meant to fulfill “custodial” needs, so you may need additional home caregiver support.

Find out about the options for services and rehabilitation after the hospital stay. There are essentially three rehabilitation options: inpatient (i.e. at a skilled nursing facility/rehabilitation center), home health care (for someone who is considered homebound) and outpatient rehabilitation (going to a clinic or center to receive therapy). We will cover these in more depth in a future post, including the insurance ins and outs & we invite you to contact us if you have immediate questions.

Ask for thorough discharge instructions in laymen’s terms and explain that you would like to be there when they are reviewed with the patient. Make a list of questions and help ensure you and your loved one are clear on instructions and who to contact if there is a problem later. Here is one example of a simple discharge form that you can provide if the hospital does not have one.

Know your patient’s rights, including the option to appeal a discharge if additional planning needs to be done to ensure a safe discharge.

Our next blog post will contain a checklist of items to consider and ask about when preparing for your elderly family member’s discharge, as well as more on resources to help during the transition of care.

Contact us if you have immediate questions. Our Florida geriatric care managers serve as your professional patient advocate, providing caregiver support and consultation, as well as geriatric assessments and resources.

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Help for Family Caregivers: When a Loved One Leaves the Hospital

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As our previous blog post points out, the hospital discharge process is a key transition time. Without proper support and resources as well as good understanding of follow up instructions, many individuals will return to the hospital for reasons that could have been avoided. No one wants this, and it can be especially dangerous for elders and persons with chronic conditions.

If you are a family caregiver and an elderly loved one is hospitalized what can you do to ensure a safe transition after the hospital stay?

Consider the discharge process as beginning at the start of the hospital stay. Find out who is responsible for discharge planning and introduce yourself, explaining that you will be involved and giving relevant information about the patient’s living situation, supports and concerns. Discharge may not seem like a top concern at the beginning of a hospital stay, but with shorter hospital stay lengths, good groundwork starts as soon as possible.

Keep good records. An online personal medical record system is an ideal way to manage your loved one’s health history, medications, and store key contacts so this information can be readily available. You can also use a notebook or file to store the information, as long as you have it available and provide good information to new providers. Make sure you communicate information that is vital to your loved one’s health, such as medications that really should not be changed or typical complications or concerns that arise during hospitalization or procedures.

Get to know the medical staff and check in about what is going on throughout the stay. Ask questions (and keep records as per above) about procedures, tests, expected outcomes, medications.

Understand that you or a designated patient advocate will need to take charge in being the centralized hub of information. This includes ensuring you understand instructions, what will happen after discharge, and the functional status of the person (and therefore what support might be needed). Ask questions and anticipate concerns that might arise and do not hesitate to voice them.

Consider using a professional patient advocate for consulting or assessment during this process. Aging Wisely’s Care Managers know the discharge process, use a systematic approach and can help families anticipate needs and find resources to help. If you are caregiving from a distance, this support is vital as it is very difficult to manage the discharge process from afar.

Plan for the immediate transition time. The first day or two after discharge can be particularly problematic. Think about practical issues such as getting new medications, food and personal items while needing to attend to a person in a weakened state. Will you be able to help the patient from bed to bathroom? Services such as Medicare home health care and medical equipment rarely arrive immediately and are not meant to fulfill “custodial” needs, so you may need additional home caregiver support.

Find out about the options for services and rehabilitation after the hospital stay. There are essentially three rehabilitation options: inpatient (i.e. at a skilled nursing facility/rehabilitation center), home health care (for someone who is considered homebound) and outpatient rehabilitation (going to a clinic or center to receive therapy). We will cover these in more depth in a future post, including the insurance ins and outs & we invite you to contact us if you have immediate questions.

Ask for thorough discharge instructions in laymen’s terms and explain that you would like to be there when they are reviewed with the patient. Make a list of questions and help ensure you and your loved one are clear on instructions and who to contact if there is a problem later.

Contact us if you have immediate questions. Our Florida geriatric care managers serve as your professional patient advocate, providing caregiver support and consultation, as well as geriatric assessments and resources.

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Problematic Transitions of Care: Elderly Hospital Discharge & Readmissions

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Everyone looks forward to being able to return to the comforts of home after being hospitalized. However, too many patients will quickly return, especially those over age 65 and with multiple conditions.

THE SCOPE OF THE PROBLEM

Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates.

Within 90 days of hospital discharge, as many as 35% of Medicare recipients will be readmitted to the hospital.

Those at highest risk have certain conditions such as heart failure, COPD (Chronic Obstructive Pulmonary Disease), Psychoses, Intestinal Problems or recent surgery; those taking 6 or more medications; and those being discharged on weekends or holidays. Older patients who live alone were twice as likely to be readmitted if they did not have supportive community services such as home care.

CAUSES

Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent could be minimized/improved.

“Decentralized responsibility is a central defect of the discharge process”, says Judith Black, M.D., MHA, medical director of senior products at Highmark Blue Cross Blue Shield. After a hip replacement, for example, an orthopedic surgeon writes orders, a primary care physician writes orders, and a case manager issues instructions. Patients are often confused and overwhelmed by the process, and even family caregivers often find they do not receive much communication or feel they understand the process.

Communication problems are thus one primary causes of problems after discharge. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Even when communication is good, patients are often groggy, medicated and overwhelmed. This is why it can be vital to have an advocate there to hear the instructions, ask questions and answer the patient’s questions later. Written instructions in laymen’s terms help as well.

Lack of good follow-up care and supportive services is another cause of preventable readmissions. Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. Family caregivers may not be prepared to care for a loved one who needs more physical assistance in a weakened state. The logistics of staying with someone while they are weak or on heavy medication and handling other responsibilities may be too much. Patients without local family support need coordinated services after they leave the hospital such as help with activities of daily living, household help, meal preparation, medication management, physical therapy, transportation to appointments.

SOLUTIONS

Our sister company, EasyLiving, Inc. provides Pinellas County home care support services such as personal care (help with bathing, dressing, grooming), household help, medication management, transportation and a special Transitions of Care Program to help immediately after hospital discharge.

Aging Wisely’s patient advocate care managers can help with the hospital discharge process, ensuring a smooth transition for you or your loved one. We invite you to review our article on elder patient advocacy and contact us today for help.

Look for our future articles on solutions for hospital discharge problems, including a checklist of things you can do, resources, and ways to be prepared.

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What is a Patient Advocate?

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A professional patient advocate is someone trained to help individuals (and their families) navigate the often complex healthcare system. Many family members and friends act as an advocate on a regular basis as a loved one faces a hospitalization, health crisis or chronic illness and treatment path. However, a professional advocate such as a care manager offers experience, training and in-depth knowledge of how to ensure the best care and pathway to good health and quality of life.

As stated by the Professional Patient Advocacy Institute, “The cost of healthcare increasingly is the responsibility of the individual consumer, which has made consumers more and more cognizant of the true cost of services and the value of traditional sources of care and information. Yet still today, the healthcare system is not set up like other commodities where comparisons can be made easily. To provide advice when faced with healthcare challenges, an emerging group of healthcare professionals known as patient advocates are positioned to assist consumers in making informed decisions while providing guidance, advice and direction in navigating the complex healthcare system.”

What are some of the ways a professional healthcare advocate helps?

*Providing a professional assessment and recommendations for resources, education and care plan options.
*Reviewing your chart and medical records to identify any concerns, questions and to help you and your family understand your health situation and options in lay terms.
*Accompanying a patient to appointments, treatment, ER visits for care continuity. Helping to formulate questions for providers and ensure good communication.
*Helping organize your medical information and create an online, personal health record.
*Assisting during key transition periods (such as hospital discharge, transfer to a care facility, or a switch in providers, where most problems occur) to ensure continuity and anticipate and avoid concerns.

When does someone use a professional patient advocate?

*When recently diagnosed with a chronic illness or acute problem–to locate good providers, evaluate options for treatments and handle the emotional and practical impacts of the diagnosis.
*During key transitions or health crises such as an Emergency Room (ER) visit, hospitalization, hospital discharge to home, inpatient rehabilitation or choosing a care facility.
*On an ongoing basis, especially when managing a chronic illness, multiple diagnoses or some form of dementia, to ensure continuity of care and be a liaison between providers, patient and family.
*To help in organizing records, putting together a care plan, creating an online personal medical record and to generally get a better handle on one’s medical situation and be proactive in managing chronic conditions.
*During end of life care, to support patient and family in decision making, emotional support and navigating options.

What are the benefits of a professional patient advocate?

*When you work with an independent advocate, such as our geriatric care managers, you get an independent assessment, someone who works for you and can ensure you get what you need.
*Expertise in the healthcare system (as well as eldercare, social services and related support services).
*Professional training and specialized expertise in the areas you need–someone who can quickly point you to resources and has knowledge of some of the issues you might not even anticipate.
*Emotional support for you and your family. Health crises can be emotional and it can be difficult to manage the practicalities and make clear decisions when facing these emotions. A professional advocate is your sounding board.

Who are professional patient advocates?

Patient advocates come from a variety of backgrounds within the medical world. Some may work for insurance companies, employers or healthcare systems or providers. Others, like our Aging Wisely care managers, work directly for the individual and family–objectively, independently–navigating a range of healthcare systems and providers and providing patients with continuity.

Our Florida geriatric care managers not only have strong professional backgrounds (both academic and experiential) in social work, gerontology, and case management, but continue to pursue specialized training areas. Our team offers experts in areas such as end of life care, Multiple Sclerosis (MS), Alzheimer’s/dementia, transitions to care facilities and much more. To read more about our professional care management and patient advocacy staff, we invite you to review our team section.

Contact us today so we can answer all your questions about patient advocacy and to find out how we can help if you or a loved one is facing chronic illness, a healthcare crisis, or just want to be assured the best quality of care.

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