Transitioning from Hospital to Home

Nicole A. Morgan, OTR, CAPS, Home Modification Specialist

Admission and discharge from any hospital can be stressful, intimidating and sometimes life altering. Many decisions must be made when you or your loved one is ready to come home. Case managers are put in place in the healthcare system to assist families and their loved ones with discharge planning and can answer any questions that the family has about the discharge process while the patient is still in the hospital. Discharge planning is a big part of hospital, inpatient rehabilitation centers, skilled nursing and long term care facilities. So what exactly is discharge planning? Medicare defines discharge planning as a process used to decide what a patient needs for a smooth transition from one level of care to another.” The way this transition is handled is critical to the health and well being of the patient and can affect how knowledgeable the family is during the transition as well. This process of learning how to transition home should begin upon admittance to the hospital and should involve the patient, family and healthcare providers. It can be difficult on the family or patient to think of all the questions they need to ask in preparation for the transition home. Here are some considerations, tips and questions to keep in mind when planning to discharge home from hospital, skilled nursing, long term care, or rehabilitation facility.

• Is the patient’s home clean, adequately heated and cooled, comfortable, safe and is there room for any additional equipment that might be needed?
• Are there steps to get into the house? Do they have a sturdy hand rail to assist the patient?
• Who can help me know how to make my home safe in order to prevent injury or falls so that I don’t take an additional unexpected trip back to the hospital? Can someone educate me while I am in the hospital on how to set up my home to be safe?
• Will a ramp be needed? Are grab bars needed in the bathroom to prevent falls?
• Will Medicare pay for the home modifications or equipment that is needed?
• Will I need to get help with bathing, dressing and basic daily activities such as cooking, cleaning, laundry and shopping?
• Will help be needed with setup of my medications, education about the medications, training on wound care, therapeutic intervention with Occupational, Physical or Speech Therapies, training on techniques of specific care?
• What resource in the community can help with necessary home modifications and would have an understanding of my situation of transitioning home from the hospital? TIP: It is a good idea to keep a notebook preferably with pockets so that you can write down names, numbers, medications, community resources and preferred providers. You can write down instructions and make lists of needed services and equipment for the discharge home. The pockets are good to keep brochures and business cards.
• Do I need special training to help myself or a loved one transfer to the car, toilet, bed or chair? Am I able to help them or will I need help once I get home?
• Can I receive transfer training in the hospital before I leave and will someone follow through with me once I get home? TIP: It is a good idea if you or your loved one has therapy in the hospital to start training and learning about what the possible expected outcomes will be physically. Ask your therapist to teach you about expected outcomes and what you should be doing at home as far as exercise program or care with activities of daily living. It is better to learn early instead of the day of discharge or the day before if at all possible. Be involved in the therapy process and treatment plan. Ask for education reading material if available.
• Which Home Health Agency will offer the best transition to home program and follow through teaching with transfers, safety in the home environment, medications, and therapeutic programs involving not only the patient but the caregiver as well? TIP: Your case manager can supply you with a list of names of Agencies that serve your county. However, a simple list will not give you specifics of what an agency provides. Ask for available brochures of Home Health Agencies serving your county.
• What community resources are available to me as the caregiver to possibly take a break from my care-giving responsibilities in order to take care of myself?

One of the keys in helping discharge planning go smoothly is to remember these three “Bs”. Be Realistic in physical, emotional and mental outcomes for the long term. Be persistent in asking questions, learning all you can about the outcomes for your loved one, discharge expectations, and physical outcomes. Persistent communication is a vital between family, physician, and involved healthcare professionals. Be prepared as much as you possibly can prior to discharge so that you can transition smoothly to home. It is important to have as many of your questions answered as possible. Being prepared can eliminate any unwanted stress that is associated with a hospital stay or discharge home. Remember overall, that discharge planning is a short term plan to get you or your loved one home from the hospital. It is not designed to be a blueprint for the future for after you get home.

First Texas Home Health and LifeTime Designs can help in this process of transitioning home from hospital or facility. LifeTime Designs is a community resource that offers the expertise of CAPS (Certified Aging in Place Specialist) certified contractors who work under the guidance of an Occupational Therapist who is a Home Modification Specialist and also CAPS certified. This team of professionals will come into your home, after the discharge or while your loved one is still in the hospital and evaluate the need for safety modifications and give recommendations to make your home safer and accessible for years to come. First Texas Home Health offers a holistic transition to home program called F.I.R.S.T. (Functional Independence Related to Safety Training). This program involves each discipline of the healthcare team so that you or your loved can remain independent and safe at home. Discharging from the hospital and transitioning home can be traumatic and stressful for patient and family. Let First Texas Home Health and LifeTime Designs work with you and your family to help make that transition a safe and smooth one.