A hospital stay is a stressful event for patient and family, and the discharge process too often adds even more anxiety. It’s important to understand, from the very beginning of a hospital stay, how the discharge process works, and how it can best benefit you or your loved one.
Every hospital has multiple professionals called discharge planners. Their job is to facilitate what happens after the patient leaves the hospital. While their work technically begins as soon you enter the hospital, typically the patient doesn’t see the discharge planner until the last minute. Be aware that every person is assigned a discharge planner as soon as they are admitted, and you may request to speak with them any time.
Depending on the reason for the hospital stay, the patient may only be there a short time. Note that the insurance coding system physicians must use to justify length of stay is complex. Medicare requires a 3-night stay in order to qualify for what Medicare defines as skilled nursing or rehabilitation. Documenting medical orders, codes, and setting up post-hospitalization care are all part of the discharge planner’s work.
If you or your loved one are experiencing a long stay that will require post-hospitalization care, it’s important that the discharge planner understands what help will be available to the patient. They may see a lot of family members visiting and assume the patient has a strong local support system, without realizing that the family are all visiting from out of town.
Be sure the discharge planner knows the answers to these questions: Is the patient living at home alone? Are there family members and friends nearby who will be able to offer practical help? If the patient is going home to a spouse, is that person realistically able to take care of the patient? Discuss with the planner the level of care the patient will need – bathing, lifting, help walking, preparing food, getting to follow-up doctor’s appointments, etc.
If it becomes apparent that the patient will not be able to go home immediately, the discharge planner will hand you a list of 10-15 different facilities, often hours before discharge, and ask you to pick three for them to inquire about available beds. More often than not, the patient and family have no knowledge about the quality of various facilities, and this sets off a frenzied and frustrating effort of calling and visiting facilities.
This is why it’s important to meet early with the discharge planner. If there is even a thought that you or your loved one won’t be going home right away, get that list of facilities right away. This is also where a local professional care management agency can be of tremendous help. A professional care manager will have up-to-date information about the best facilities. Just because Uncle Charlie had a good experience at a facility two years ago, it doesn’t follow that the facility is still a good choice. Facilities change owners and management teams frequently, and quality is largely dependent on the outlook and talents of the personnel.
It is also important to conserve the energy and availability of the family for the rehabilitation period. Having everyone rush in from out of town and descend on the hospital can be less than helpful. Try to arrange for visiting family, those willing and able to offer practical help, to schedule their visits over the course of the rehabilitation period. With good planning, your loved one might even be able to avoid a facility and go directly home to be cared for by a combination of family and home nursing visits.
A professional care manager can offer invaluable help with post-hospitalization planning, offering alternatives for care, and working with the patient and family to create the smoothest transitions possible from hospital to rehabilitation to home.
