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Care transitions

From hospital to home, rehab or long-term care

During your caregiving journey, there may be times when your care recipient needs to change from one type of care to the next, or from one care setting to another. They may, for instance, be discharged from a hospital to a rehab centre or need to move from their family home to a long-term care facility. 

In order to make this transition as easy as possible for all concerned, it’s important to do your homework and be ready with a viable plan. You’ll feel better and so will your parent. Knowing what to expect and anticipating concerns or issues can greatly impact how a patient heals, improves or adapts. Not only should your plan should include the process and logistics but also everything your care recipient needs for a smooth move to an alternate level of care.

Talk about it
When helping someone transition from a hospital or rehab to home or other care facility, the first step is to discuss what’s going to happen with your care recipient and their healthcare team. You’ll need to determine whether you, as the family caregiver, will need any training, what devices, might be required and if there are medications involved. Will anything in their new home or the next facility needs to be modified to accommodate their physical needs and what additional supports might be required. Don’t forget to sort out necessary referrals and arrange for any follow-up appointments as well.

On the day your family member is leaving their current location, you should be given a discharge summary or package.  It may include something similar to The Discharge Checklist, created by The Change Foundation, Cornwall Community Hospital and Cornwall & District Family Support Group. Even though it’s for a hospital discharge, the material is a good example of the types of information and records you’ll need to have on hand.  

It starts with admission: Know that discharge planning from a hospital starts the day the patient arrives. As your parent’s advocate, you will learn what he or she needs during the hospital stay. 

• Get involved: Observe as much as you can during your parent’s hospital stay about the diagnosis, treatment plan, new medications and daily care. There are many resources to help you, but discharging a patient can often be overwhelming and confusing for the caregiver. You may worry about being able to take care of your parent after leaving the hospital or overwhelmed by the amount of information you have to digest about their daily care and might be concerned about a medical error, like a medication mistake, or relapse that could send your parent back to the hospital, known as a hospital readmission. 

• Relax. Or try to anyway. The hospital will have a discharge planner, hospital social worker, charge nurse or your parent’s primary nurse to go over all the discharge planning with you. Here are some of the steps you can take to make sure you understand what is needed to avoid a hospital readmission. 

Ways to avoid a hospital readmission:
The Canadian Institute for health Information estimates that 8.5 per cent of patients are readmitted within 30 days—a figure all of us would like to see reduced. Helpful suggestions include:

• Be present at the time of discharge: If the patient is returning home, you’ll want to know
what kind of care will be needed. Make a list of questions before discharge. Write down the answers in a notebook you’ll refer to later.

Ask the patient’s primary nurse to go over daily care of the patient: Take notes in a notebook that you can refer to later and ask the nurse to show you what needs to be done—watching someone complete tasks is helpful, rather than simply relying on your written notes. Those serve as back-up. Ask the primary nurse these three things:
–What is the main problem?
–What do I need to do?
–Why is it important for me to do this?

Involve the family doctor: Always involve the patient’s primary care physician (PCP) in the process of discharge from the hospital. PCPs can help with transitions to home, give you essential information about the patient’s home setting, potential risks at home, and inform you of follow-up appointments with the physician. Write everything down in your notebook. Make sure the patient’s PCP has a list of all new medications.

Literacy and language. If your parent speaks another language, ask for discharge planning instructions in the language he or she speaks. Ask if the hospital has an available translator for the patient. If needed, find a family member or good friend who can translate for your parent. Take notes in your parent’s language so he or she can refer to them later.

Write it down. Be it the patient’s diagnosis, list of medications and dosages, dietary needs, any treatment needs, test results and any pending test results, it’s best to keep a written copy.

Fill prescriptions. Consider filling new prescriptions before the time of discharge or before leaving the hospital. Ask if there are potential side effects of any new medications and write them down.

Funding. If your parent cannot afford any new medications, do not be embarrassed to tell the primary physician, primary nurses, discharge planner or social worker. There could be options.

Ask about any dietary restrictions. Then consider who will do meal preparation if your parent cannot do this for him or herself.

Medical team. Make a list of which health professionals will be helping with the care
of your parent. Who will be visiting and how often? What are their names and contact information?

Warning signs. You’ll also want to ask the primary physician or primary nurse for any potential warning signs of a medical emergency or urgent problem that requires medical attention. You’ll want to know the signs if your parent is not doing well. You might consider making a list for your parent for his or her home that says:
–Call 911 if you experience these symptoms (list them)
–Call your doctor if you experience these symptoms (list them)
–Go to the hospital ER if you experience these symptoms (list them)

Create these lists according to the information the patient’s primary physician or primary nurse tells you. Place it on your parent’s refrigerator or bathroom mirror.

• Recovery time. Ask the patient’s primary nurse and primary care physician what the anticipated recovery time will be. Record the information in your notebook.

Other Resources. Before your parent’s hospital discharge, ask the patient’s primary nurse, primary care physicians, hospital social worker and discharge planner for a list of the following:
–Community resources of social support for caregivers and patients.
–Community-based agencies that provideservices such as transportation, equipment maintenance, homecare and volunteer services.   

Adapted from

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