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Discharge Planning Starts at the Beginning of a Hospital Stay, Not the End

Today's Medicine

Published: August 17, 2020

 

You’ve been admitted to the hospital. You’re overwhelmed and scared. You may not know why you’re having that symptom or feeling that pain. You feel vulnerable and have to quickly learn to trust your care team. The last thing on your mind is whether you’ll need a safety bar in your shower or who’s going to grocery shop for you once you get home. 

What might surprise you is that there’s a team of people thinking of those things and more the moment you’re admitted to the hospital. While you’re focused on healing, they’re working side by side with your care team to create a realistic discharge plan that meets your needs, keeps you safe and helps prevent a return to the hospital. 

 

The importance of caregivers

The discharge conversation starts soon after you’re admitted. Discharge planners work closely with your providers to understand the care goals and potential barriers to discharge. They work to eliminate those barriers to smoothly transition you back to your home or a post-acute care facility. 

That’s when the conversation starts happening with your caregiver as well. They’re the expert on you. Discharge planners need to understand your living situation and support system. The more present your caregiver is at the hospital, the better sense discharge planners have of your baseline and whether your recovery needs are too extensive for home. 

Caregivers, be honest about what you’re able to handle. Maybe you have an employment or financial situation that prevents you from giving your loved one the care that they need. Help paint a clear picture of what’s happening at home so everyone can arrive at a discharge plan that makes sense.

The nursing staff is there to educate you on dressing wounds, emptying drains, administering medicine, etc. But you also need to ask yourself if you’re comfortable being that care person and if you understand the extent of what you need to do and how to do it. 

There’s no shame in admitting that you can’t care for your loved one at home. Communicate that as early as possible so discharge planners can begin the process of looking into a post-acute care facility or helping you find in-home assistance. It’s easier to cancel plans if you get to a place where you’re comfortable caring for your loved one than to find out at discharge that going home is not a realistic option for them.

 

Get SMART about discharge

Much like a hospital stay, discharge can be overwhelming. As a patient or caregiver, you’re processing a lot at once. A simple acronym – SMART – can help you understand what’s expected of you and what kind of questions you need to ask. At discharge, you and the care team should review: 

S – Signs and symptoms that need to be reported to the patient’s provider
M – Medications that need to be taken and instructions for each
A – Appointments that need to be arranged 
R – Recommendations and restrictions for the patient's care 
T – Talk about any questions or concerns you have before discharge

If you don’t understand something, ask! There are no dumb questions. Something that may seem normal to a health care provider can be new to you. Continue to ask questions once you’re home. Ideally, discharge should occur early in the day, which gives patients and caregivers time to process that transition out of the hospital and ask follow-up questions while their provider’s office is still open.

 

Discharge in the COVID-19 era

The COVID-19 pandemic has touched almost every process at hospitals, and discharge planning is no different. Depending on a facility’s visitor policy, caregivers may not be allowed to visit, or their hours may be limited. Care teams and discharge planners have had to rely more on technology to determine if a patient is close to their baseline. Communication and education with caregivers has become more intentional, requiring discharge planners to think even further ahead to ensure a caregiver is present at discharge to receive education. 

COVID-positive patients present a different challenge because of stricter visitor policies. Recovered patients may be returning to a household where others were infected but never developed serious symptoms. It takes extra communication and education to help those family members understand the care their loved one requires. And many discharged patients who are still COVID-positive face logistical challenges. Can they isolate in the home, or does the discharge team need to help them with other accommodations? The discharge process will be affected by COVID-19 for many months to come – communication and education remain key.  

 

A team that has your back

The goal of discharge planners is to provide a safe discharge plan, sturdy enough to ensure that readmission isn’t likely. Early, honest communication between caregivers, the care team and discharge planners is essential to that process. And as you go home, remember that SMART acronym. Missteps happen when communication is weak or a patient modifies their care plan without discussing it with their provider. Discharge planning is complex, but you should never feel alone as a patient or caregiver. A whole team has your back. 

 

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Carrie Phillips

About the Author:

Carrie Phillips, MSN, RN, CCM, had an initial interest in labor and delivery but ultimately found her niche in care coordination and care transitions. She is now the service leader for care management and acute dialysis at Methodist Hospital and Methodist Women’s Hospital, and what she enjoys most about her profession is also the hardest part.

“The most difficult part of my job is taking a really complex case and working to find solutions,” she said. “Some cases challenge us to be really creative and collaborative, but these are the most rewarding.”

Phillips received her Bachelor of Science in nursing from the University of Nebraska Medical Center and her Master of Science in nursing from Nebraska Methodist College. She is certified in case management.
 

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