About UsTransitioning 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.
Making Your Home Last a Life Time
A Plan to Age in Place
By Nicole A. Morgan, OTR
Home Modification Specialist
Life Time Designs
What does it mean to age in place? Aging in place means that you are able to secure the necessary support services and modify your home in order to live in your current residence for as long as you are physically and reasonably capable. Aging in place is a choice that empowers an individual over their independence and quality of life. The decision to age in place is not just for the “older” population, but one that everybody should consider in their adult life no matter what stage of life they are in. As you prepare to age in your current home, ask yourself these three questions: Is my home set up to be safe for the coming years and what may lie ahead of me physically? What modifications do I need in order to make my home safe to age in place? What community resources are available to help me with aging in place? Other areas we must address when deciding to age in place are healthcare, family support, and financial security, although our foundation is the place where we live day to day. According to CDC (Centers for Disease Control) statistics, one in three people over the age of 65 fall each year. Falls are the leading cause of injury deaths and the most common cause of injuries and admissions to the hospital. The majority of these falls, occur in the home and can be prevented with home safety modifications.
When we are young, we build or remodel homes that are convenient and comfortable for us and our lifestyle. As we accept that we are aging, we realize that the home we chose in our younger years should be aging with us. Home modifications are one of the best solutions for aging in place. Applying safety home modifications can help you improve independence with activities of daily living, mobility, balance, dignity and the overall quality of life. Without them, your daily outcomes can lead to unsafe habits, environments, and compensations for daily activities which could result in falls, a decrease in independence, and a decline in quality of life. Rather than the misconception of making your home look like an institution, home modifications for safe aging in place may be your solution from having to live in a nursing home or with assisted living. Now is the best time to have your life time home assessed for safety and the modifications needed for aging in place, regardless of your age or stage of life. You don’t want to wait until you are well into the aging process or after an injury has occurred to make these modifications. Take the opportunity now to prepare appropriately for a safe environment for the rest of your life in your current home, or the one you are purchasing or remodeling.
Anyone can perform a basic assessment for safety in their home if they know what to look for. Many safety checklists are available to the public that help make your home safe in order to reduce the risk for falls. To increase safety, we have provided a list of suggestions that could be applied to every room of your home.
- Make sure all pathways for walking are clear and free of clutter and furniture.
- Remove any unsecured throw rugs.
- Secure all loose wires from lamps, extension cords or telephones.
- Remove clutter, especially in walkways and on the floor.
- Make sure each room is well lit.
- Move items that you use everyday within safe reach.
- Use non-slip rubber mats or strips in the bathtub/shower and on the floor.
- Have grab bars or stair rails installed to have a secure hand hold and safe transitions.
- Plug in night lights in or very near your pathway from your bed to the bathroom for night time use.
- Have portable phones available throughout the house or an emergency response system in place.
Performing a safety checklist assessment is only one step in preparing your home to age in place. Universal accessibility is becoming a more common term that is used with home modifications, safety risk assessment, and aging in place. By adding universal modifications, you can actually increase the value of your home due to the current progressing trends of aging in today’s society and along with the endless choices of aesthetically pleasing modifications that can be constructed or purchased. Making your home universally accessible means your home not only has minimal safety risks, but has all the necessary modifications needed to accommodate common aging challenges that we face with mobility such as balance and standing, bending and reaching, reduced hearing, grasping and holding, sitting and lying down, and lastly, poor eye sight (low vision). Universal and basic home modifications can include adding a ramp, constructing a step-less entry, widening doorways and hallways, lowering counter tops and cabinets, threshold ramps, installing grab bars and hand rails, walk-in showers, lever door handles, plus many, many more to accommodate your specific needs.
Life Time Designs is a community resource available to those who are aging and who are planning to age in place. We are unique in that we offer the clinical expertise of the Occupational Therapist who is certified in home modifications, has the ability to properly assess a home for safety risks for falls, and makes the necessary home modification recommendations for universal accessibility for aging in place. The Occupational Therapist is partnered with a CAPS (Certified Aging in Place Specialist) Contractor and by consulting and working together, the client gains a modified home and the education they need for continued safety. Our mission is to provide safe, reasonable, aesthetically pleasing home modifications whether they are large or small to our aging community and to provide the education necessary to maintain a healthy, safe lifestyle in order to realistically age in place.
Let us help you, Make Your Home Last a Life Time.
