DIscharge Planning and BTS Home Care SERVICES
Things to Consider Prior to Discharge to Ensure Continuity of Care
In-home care plays a vital role in facilitating a smooth transition for seniors being discharged from a hospital or rehabilitation facility to their home. There are many things to consider in advance in an effort to reduce stress for both patient and supporting family. Consider the following:
Patient Restrictions and Activities
Will your loved one be able take a bath or shower, lift heavy items, walk upstairs on their own, or do they require direct assistance? If assistance is required, how much and how frequently? Are you and/or family members prepared to help with care or rehabilitation? If yes, what is the division of labor, and how much assistance should be outsourced to professional caregivers?
Special Care Tasks
What care tasks are needed to render care, or is special training required to better assist your loved one? If special care is required and you are unfamiliar with such tasks, be sure to ask for specific instruction from attending nursing staff before you leave the hospital or facility.
Special Diets
Will any special foods need to be purchased or prepared in advance? If yes, do you have easy access to such items? Do you have the necessary tools to prepare the food? For example, if you loved one requires a liquid diet, do you have a blender with associated items or tools to prepare each meal? Can meals be prepared in advance? Who will prepare and store the food, and for how long will the food remain edible?
Medication Management
Will you be able to ensure the correct medication and dosage is taken at the right time? Especially when required to take half a dose, and the medication is in pill form, are you literally able to divide the pill?
If possible, ask for a visual chart or detailed instructions explaining all medications, and when each should be taken. Does the medication need to be taken with a meal or on an empty stomach? Will you need to wake up your loved one to take medication? If yes, who will be responsible for waking them to administer medication?
Be sure anyone helping to provide care is aware of possible side effects from the medications. Can the medication cause dizziness, drowsiness, or other side effects that will require close monitoring? If so, a division of labor should be implemented to ensure someone is available to monitor your loved one.
When will medications need to be refilled? If taking multiple medications, chances are very good refills will come and different times. Who will be responsible for monitoring, picking up, or coordinating refill deliveries?
CREATING A CUSTOM CARE PLAN
In addition to considering support personnel, developing of a targeted and effective care plan is critical for ensuring continuity of care. Several key factors should be considered to include overall medical condition, your loved one's functional abilities in relation to their personal habits and preferred routines, along with all expected necessities such as personal hygiene, including bathing, oral care, toileting, and skincare. Further considerations are physical therapy and exercise. How will exercise and mobility be incorporated into the care plan to improve strength and flexibility?
Also, emergency preparedness is a must. What is the plan for responding to medical emergencies or unexpected events? Where will your loved one's medical records and care plan be saved/stored for easy accessibility by emergency care staff?
Follow-up Care
For follow-up appointments, who will be responsible for coordinating appointments and transportation? For in-home appointments, who will be responsible for preparing your loved one for the arrival of the medical professional?
Equipment and Supplies
In addition to special foods, you may need to shop for specific equipment and supplies. Are they covered by insurance? If yes, in part, in full, or will someone need to pay out-of-pocket? If out-of-pocket, who is going to pay? Who is going to pick it up? If items are covered by insurance, who will be responsible for turning in necessary receipts and paperwork to ensure reimbursement? Who will be responsible for cleaning and sanitizing the equipment?
Home Safety
What changes are needed to ensure safety - removing trip hazards such as loose rugs and cords. Does furniture need to be moved or altogether removed to accommodate something like a medical bed or large equipment?
Finances and Associated Expenses
Who will be responsible for managing your loved one’s finances and possibly paying necessary bills and housing expenses? For obvious reasons, this is a very important topic that requires very serious consideration and accommodations. Despite the condition of your loved one, rent and/or mortgage payments, taxes, home maintenance and repairs need to continue to be properly managed and maintained.