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Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay. Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
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The goal of the IDEAL Discharge Planning strategy is to engage patients and family members in the transition from hospital to home, with the goal of reducing adverse events and preventable readmissions.
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- Legal Issues Affecting Caregivers
- What Is Discharge Planning?
- Why Is Good Discharge Planning So Important?
- The Caregiver’S Role in The Discharge Process
- Discharge to A Facility
- Paying For Care After Discharge
- What If You Feel It’S Too Early For discharge?
- Basic Questions For Caregivers to Ask
- This Is A Lot of information. Any Advice For People New to All of this?
- Additional Resources
HIPAA: The Health Insurance Portability and Accountability Act
You may have heard about HIPAA restrictions. HIPAA rules impact the sharing of information about patients in medical care. Although when the act was first initiated there was some confusion about how much information families and caregivers could receive about a patient’s medical situation, it is now clear that information must be shared. 1. The US Department of Health and Human Services says: If the patient is present and has the capacity to make health care decisions, a health care provider...
Advance Health Care Directives
These documents clarify who will speak for patients if they cannot speak for themselves. 1. The documents may be referred to as living wills, health care proxies or Durable Powers of Attorney for Health Care. 2. These documents can only be completed when a person is competent to do so (if someone has dementia, talk to the doctor about whether they still are competent to sign a legal document). 3. They include instructions on the type of care individuals desire if they are very ill or dying. 4...
Caregiver Advise, Record, Enable (CARE) Act
The CARE Actis in place to ensure hospitals aren’t discharging patients without preparing family caregivers. With the CARE Act, hospitals must do three things: 1. Record the name of the family caregiver on the medical record of the person being cared for. 2. Inform the family caregivers when their friend or family member is to be discharged. 3. Provide the family caregiver with education and instruction for the medical tasks he or she will need to perform for the patient at home. The CARE Act...
According to Medicare, discharge planning is a process that determines the kind of care a patient needs after leaving the hospital. Discharge plans should ensure a patient’s transition from the hospital to another medical facility or to their home is as safe and smooth as possible. Only a physician can authorize a patientʼs release from the hospita...
The main reason discharge planning is such a priority – not just for hospitals and care teams, but also the U.S. Centers for Medicare and Medicaid Services – is this: Effective discharge planning can decrease the chances the person you care for is readmitted to the hospital. A thoughtfully developed plan aids recovery, ensures medications are presc...
The discharge planner will look to you, the caregiver, for history and insights about your friend or family member. As their advocate, you are likely to play a central role, managing many vital tasks: 1. collect information 2. speak to doctors 3. transport the patient 4. ensure lab tests are done 5. pick up, prepare and give medications 6. research...
If the patient is being discharged to a rehab facility or nursing home, effective transition planning should do the following: 1. ensure continuity of care 2. clarify the current state of the patientʼs health and capabilities 3. review medications 4. help you select the facility to which the person you care for is to be released
Understanding and navigating payment for after-hospital care needs: 1. You might not be aware that insurance, including Medicare, does not pay for all services after a patient has been discharged from the hospital. 2. Certain skilled care or equipment, however, may be covered– if it is determined by the doctor to be “medically necessary.” 3. Gather...
As their advocate, you have the right to appeal a decision to discharge your friend or family member from the hospital if you think it’s too early or if you think discharge to home is not safe. 1. If you don’t think they are medically ready to leave the hospital, your first step is to talk with the discharge planner (often a social worker) and expr...
Questions about the illness:
1. What is it and what can I expect? 2. What should I watch out for? 3. Will we get home care, and will a nurse or therapist come to our home to work with my friend or family member? Who pays for this service? 4. How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments? 5. Have I been given information either verbally or in writing that I understand and can refer to? 6. Do we need special instructions because the person I care for...
Questions when the person I care for is being discharged to the home: *
1. Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment? 2. Are there stairs? 3. Will we need a ramp, handrails, grab bars? 4. Are hazards such as area rugs and electric cords out of the way? 5. Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment? 6. Who pays for these items? 7. Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?...
Questions about training:
1. Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment? 2. Have I been trained in transfer skills and preventing falls? 3. Do I know how to turn my friend or family member in bed so they don’t get bedsores? 4. Who will train me? 5. When will they train me? 6. Can I begin the training in the hospital?
We know it can feel overwhelming. Here are three steps to make it a bit more manageable: 1. Print this fact sheet – the whole thing – and take it with you any time you will be visiting the hospital or meeting with a clinician or other member of your friend or family member’s care team. Use it as a reminder of topics and questions you want to cover....
Family Caregiver Alliance National Center on Caregiving (415) 434-3388 | (800) 445-8106 Website: www.caregiver.org Email: info@caregiver.org FCA CareNav: https://fca.cacrc.org/login Caregiver Services by State https://www.caregiver.org/connecting-caregivers/services-by-state/ Family Caregiver Alliance (FCA) seeks to improve the quality of life for ...
The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners, and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.
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Discharge planning helps to make sure that you leave the hospital safely and smoothly and get the right care after that. You, the person who is caring for you, and your discharge planner work together to address your concerns in a discharge plan.
During your stay, your doctor and the staf will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. You can use this checklist to prepare for your discharge.
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How can hospital discharge planning improve patient health?
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Apr 3, 2023 · Discharge planning is the process of transitioning a patient from one level of care to the next. Ideally, discharge plans are individualized instructions provided to the patient as they move from the hospital to home or instructions provided to subsequent healthcare providers as they move to a longer-term care facility. [1]
