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Resources & Services After Hospital Discharge: What Can You Expect? - Aging Wisely

We have previously shared some of the challenges patients face after hospital discharge, which often result in avoidable problems and unnecessary readmissions. If someone you care about is in the hospital, visit our Tips and Checklist for Hospital Discharge.

One challenge family caregivers most often face when a loved one is in the hospital is navigating the healthcare system and learning what resources are available to help. This is one reason why a professional patient advocate such as our geriatric care managers can be so helpful. We get many calls from families wondering what type of support their loved one can expect after they leave the hospital, what services are available and what insurance will cover for in-home care or rehabilitation.

Most Medicare recipients will either leave the hospital for inpatient rehabilitation (skilled nursing and therapy, typically provided at a Skilled Nursing Facility i.e. nursing home) or return home and receive some therapy or nursing services under Medicare while they recuperate. The choice depends on patient and family preference, patient’s condition and intensity of need, supports at home and a variety of factors (including doctor and case manager recommendations/opinions).

When considering these options, keep in mind the many factors involved in the recovery period. Older patients, especially those with multiple conditions, may benefit from the supports and therapeutic regime in inpatient rehabilitation, though most people prefer the idea of returning home as soon as possible. In an inpatient setting, most patients will receive daily therapy and have round-the-clock nursing services, which may be especially useful for an older patient who lives alone and wishes to regain much strength and independence. Typically, Medicare pays for up to 20 days of inpatient rehabilitation after a three day hospital stay (if it is considered medically necessary) and up to an additional 80 days with a copay (see our Medicare 2011 Fact Sheet for Medicare copays and costs) that is often covered by supplemental insurance. If you have a Medicare Advantage or private insurance plan, your coverage may differ and you may have to select a preferred provider to get full coverage.

For more information on Medicare’s coverage for home health services and in-home therapy, see our article. When leaving the hospital, it is important to plan ahead and set up services to cover custodial needs and fill the gaps that are not met through Medicare skilled home health coverage. For example, transportation home from the hospital; someone to pick up prescriptions, groceries and personal items; personal care and safety assistance during the key first 24 hours; help preparing healthy meals according to dietary needs; reminders about medications; transportation to after-care and appointments. EasyLiving, Inc. offers all of these home care services in Pinellas County, Florida.

Good senior nutrition is key to a healthy recovery. Make sure to ask your doctor about dietary restrictions, how medications might affect appetite and advice about taking medications with meals (before or after, does the medication sometimes cause stomach upset?, are any foods contraindicated?). If a person is having difficulty healing or with weakness, or has had recent weight gain or loss, a consultation with a nutritionist may be in order. He or she can analyze your current diet, create a personal meal plan and discuss supplements.

Medications frequently change during a hospital stay. Make sure you are maintaining good records of past medical history and medications, a current list and instructions for medications, and alerting physicians (and home care providers) of these updates. Aging Wisely uses Caregiver’s Touch, a dynamic online portal for clients and caregivers that serves as a central, accessible location for personal health records. This tool reduces inconsistencies and provides immediate access to information and improved communication. Contact us today to learn how we can help organizing and creating your personal health record.

Your loved one may need help adjusting to a new medication regime. If he or she receives Medicare skilled home health care, the nurse can assist with setting up a medication box and patient teaching. Private duty home care medication management and reminders may be needed on an ongoing basis, or for initial assistance in adapting to the new routine.

today to learn more about resources and services to help after hospital discharge, for Florida geriatric care management, Clearwater home health services, and patient advocacy.

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