Planning for Safe Discharge
It's probably something we don't think of until it happens to us or someone close to us. Health issues can arise without warning and leave us with a number of unknown questions with even fewer answers.
Arriving to the hospital and going through tests, procedures, therapy, and much more can be overwhelming and exhaustive. "So what happens when I'm discharged from the hospital and find myself in a Transitional Care Unit (TCU) and how do I prepare for the next transition after my discharge from here?" As the Rehab Director of a Continuous Care Rehabilitation Campus (CCRC), I have watched families overlook this question repeatedly and have it lead to last minute scrambling, additional expense, and the possibility that people are not able to get into the type of facility that best suites them at the time of discharge.
Upon arrival to a TCU you will receive care from several areas including, but not limited to, nursing, therapy (PT, OT, SLP), dietary, social work, activities, and spiritual care. You have a team of dedicated professionals working together to increase your independence, decrease the level of assistance you need, and start your discharge (DC) planning right away on day one.
Many people are surprised to hear about discharge planning on day one, but this is an often overlooked yet vitally important aspect to your stay. Nursing will manage medical aspects and potential complications while ensuring that you have the right medications ordered and ready for you at DC. Dietary will assess appetite and make sure you are eating a diet that promotes healing/recovery and also discuss your ability to get and provide meals for yourself once you transition out of the TCU. Therapy consists of physical, occupational, and speech language pathology. Each discipline focuses on movement, transfers, strength, range of motion, activities of daily living (ADLs), cognition, eating/swallowing, and receptive/expressive communication. The facility social worker (SW) is the ringmaster trying to pull all the information together. The SW will ask for input from all other areas and help with DC location planning, and DC services. All of this for a safe DC.
"What is a safe DC?"
It is a DC plan that takes into the following information and is designed for your best possibility for success while mitigating your risk for rehospitalization:
DC Location - Can or should you return home? Are there steps outside or inside the home? Are there any other physical barriers that the team needs to be aware of? Were you in a long-term care (LTC), assisted living (ALF), or independent living (ILF) facility?
Assist Level - How much assistance will you need after the TCU? Do you have family or friends to help? Are private home health services an option? Have you had a change in cognition that makes it unsafe for you to return back to the location you were at prior to the health crisis?
Durable Medical Equipment (DME) - What do you currently have and what do you need in order to minimize falls and decrease the level of effort needed by a caregiver to assist you throughout the day?
Access to Food - Are you able to get food, prepare it, and is it appropriate for you?
Access to Medication - Do you have the correct medications? Are you able to take correct dosages at the right times? Do you know what to do if you happen to miss a dose?
Additional Services - Do you need therapy or nursing skilled services at home? Do you have a social activity plan?
Isolation - Will you be living by yourself? Are you active in your community? Do you have reliable transportation and/or the ability to get to and participate in different activities?
There is a lot that goes into a safe DC from the TCU. The last question to ask yourself is, "Now that I'm home, how do I reduce the risk of another health crisis and possible hospitalization?"
Review the seven points above and ask yourself the questions. If you find yourself limited in one or more areas, reach out to community programs, friends, family, appropriate medical attention, or other organizations that specialize in assessing and addressing the specific areas of deficit.
While using the above points and questions as a guide is not a guarantee to avoid hospitalizations, it can be helpful to reduce the likelihood and keep you aging in place and improve your quality of life!
