When an older adult is discharged from the hospital, families quickly become the primary source of support. Responsible for meals, medications, transportation, and more, family members must fill the gaps that are left by the hospital. The best time to identify these gaps is right before the patient is discharged. For families in Lawrenceville, Duluth, and Snellville, non-medical home care can help bridge the gaps in everyday needs that clinical services do not address.
I have found that families feel less overwhelmed about the many new responsibilities that are placed on them as a result of the patient’s hospital stay when they have a plan about who will be doing what before the patient comes home.
Hospital discharge plans may outline a patient’s medications and the follow up care they will receive. They may not include a plan to address who will help a patient get dressed in the morning, take them to a follow up appointment, or help them if the family caregiver has to return to work.
All of these details are important.
What Kind of Gaps Can a Hospital Discharge Plan Have?
Responsibility changes dramatically for an older adult when they are moved from a hospital to their home.
In the hospital, staff is responsible for meeting a patient’s needs for food, medication, and other needs. At home, the responsibility may suddenly fall on the patient or their spouse, family member, or caregiver.
What good is a prescription if nobody can pick it up?
A patient may have a dated follow-up appointment time, but who will do the driving?
There are activities a patient is restricted from doing, but who will plan for how the patient can get from point A to point B?
Moving in a hospital room is also different from moving around a house. There may be obstacles at home like stairs and a narrow pathway to the bathroom. Also, there may be everyday activities that were not the same in the hospital, like a different morning and bedtime routine.
And let’s not forget the family caregiver.
Someone who helps for the first few hours may not be able to help for the hours that follow, like in the morning, evening and appointment times.
Answering these practical questions helps create a better discharge plan for the patient and family.
A Hospital Discharge Checklist for Gwinnett Families
Before the patient is discharged, I go over the following questions with the patient and family.
Go over discharge instructions
Understand the instructions the healthcare team has provided and guide the family through this if it is needed.
Ask about unclear parts of the instructions before leaving.
Understand the plan for medication
Understand which medications are to be taken, when and who is the contact person for medical questions.
A family member may have to help plan the household activities around these instructions.
Make a list of all follow-up appointments
For each follow-up appointment include:
- Date and time
- Location
- How the patient will get there
- Who will go with the patient if they need help
- Who will make sure the patient gets follow-up appointments
The follow-up appointment is just one part of the plan.
Think about what your normal day would look like if no one was helping you.
Think about what your day would look like from getting up in the morning to going to bed at night.
Are you able to:
- Get up from a seated position?
- Bathroom?
- Get dressed?
- Prepare meals?
- Move from room to room?
- Use the stairs?
- Get to your appointments?
- Do everything the healthcare team wants you to do to help get better?
Being able to answer these questions will help you see what gaps are still in your plan.
Think about who will give you the help you need to get better.
Will a relative help? Will a friend help?
Once you identify who will help think about when they will be able to help.
What is the difference between home care and home health care?
Home care and home health care services do different things and sometimes a person may need both when they return home from a hospital, nursing home, etc. Home health care is health related and is done by a trained health care professional. Home care is not health related and is done to help a person with their daily activities.
Home Instead Care Pros helps clients with tasks based on the Care Plan, including personal care tasks, meal preparation and assistance, transportation, household duties, and reminders for personal care tasks and medication.
There are differences, however, between the two services.
Home health care professionals may provide clinical services in the home, but that service usually does not extend to provide the client with other non-clinical needs for the day.
- A client may still need assistance in preparing meals.
- A client may still need help with getting dressed.
- A client may still need transportation.
- A client may still need care during the time the family caregiver is at work.
Home health care and non-medical home care services can serve clients together.
What Can Home Care Help With After Hospital Discharge?
Home Instead has local services that can assist clients with various daily living activities including:
- Meals
- Personal care
- Dressing
- Housekeeping
- Transportation
- Errands
- Medication reminders
- Other daily living activities
A Care Pro cannot take the place of the client’s medical provider.
Care Pros, for example, can remind clients to help them complete a routine for taking a medication, but a Care Pro can’t make a medical determination or provide instructional changes.
Should a client’s condition change, a member of the client’s healthcare team should be contacted.
If a client needs emergency medical services, call 911.
How Quickly Can Home Care Begin After Discharge?
The best approach is to call before the patient leaves the hospital.
The current Home Instead Norcross/Lawrenceville office notes that care can often begin within about 48 hours, depending on the situation, Care Pro availability, the requested schedule, and the support required.
It should be noted that not every request can begin within 48 hours.
A family requesting a few specific hours of support may have different scheduling needs than a family requesting extended daily or around-the-clock support.
The earlier the office has an idea of what the needs are, the more time the office team has to consider the request and create a Care Plan.
What we are essentially saying is that for families located in Lawrenceville and the surrounding service area, it would be best not to wait until the first day home to discover that help can’t be provided on the second day.
When requesting home care services, what information should be given?
When requesting home care services, it is best to be prepared with detailed information to optimize the time spent on the call.
Be able to talk about:
- After discharge, where will the person live?
- What will be the person’s discharge date and time?
- In what hours is help needed?
- What Activities of Daily Living (ADLs) does the person need help with?
- Who else will be living in the house?
- What family members can realistically help?
- Will home health, therapy, hospice or other clinical services be also providing visits?
- What are the transportation needs?
- What are the routines for mealtime and housework?
- What impact do changes in mobility have on daily activities?
A care consultation will then be able to address what activities the individual cannot do as opposed to a general “be there.”
What About the Family Caregiver?
Hospital discharge planning will rightfully focus on the patient. I also want to learn about caregivers who will be providing unpaid care.
A daughter may be able to take a few days off from work.
A spouse may be able to provide care during the day but may be unable to provide all of the physical assistance needed.
A relative may live farther away.
The plan should account for these differences.
Family caregivers also have jobs, appointments, errands, and their own health. Home care can replace family care only in the most dire situations. The family caregiver can then take time off from caregiving or it can fill the gaps when care is needed during a time when family support is not available. Home care can provide respite care to the family in Lawrenceville when it is needed.
For Case Managers and Discharge Planners
In Gwinnett County, when a patient has non-medical needs beyond their hospital stay, Home Instead may be part of the support plan, along with clinical providers and the family.
If a patient is expected to be discharged to an unsafe or otherwise undesirable living environment, Care Pros may be able to assist with agreed-upon daily routines such as meals, personal care, transportation, companionship and other activities, in addition to providing general oversight as part of the home care team.
It is important to determine the delineation of responsibilities of the medical team, family, and other providers.
For individuals living in Lawrenceville, Duluth, Snellville and surrounding communities served by the Norcross office, call (770) 972-2273 to discuss and assess care needs.
Home Care Questions and Answers
When should I call about home care after a hospital stay?
You should call as soon as you begin to think the patient may require support once discharged to the home environment. The home care team may be able to provide meaningful support and resources to the family during the post discharge period. Contacting the office before the patient is discharged from the hospital may provide additional resources and support to assist the patient once they are discharged.
Can home care start the same day a patient is discharged?
It is dependent upon the situation and availability. Care may start within 48-hours, however not all requests may be immediately available. Contacting the Norcross Home Instead office prior to patient discharge provides the opportunity to create a plan for care once the patient is discharged.
Can a Care Pro help with medications?
A Care Pro may provide medication reminders based on the Care Plan. Home care does not cover the medical professional making the decisions regarding the client’s medications. Questions pertaining to prescriptions, dosages, side effects, and/or any change in a client’s medication should be directed to the client’s health care professional.
What is the difference between home care and home health?
Services of home health generally include clinical services and are provided by a licensed professional (nurse, therapist, etc.). Home care consists of mainly non-medical services such as personal care (e.g., getting dressed and/or bathing, etc.) and/or routine tasks (e.g., meal preparation, light housekeeping, etc.) and may include medication reminders. Some clients may receive both home health and home care services.
Can I arrange care for my parent if I live outside Gwinnett County?
Yes. A family member living outside of Gwinnett County can start the conversation about parental care, as long as the parent lives in the service area of the nearest local office. The care team can explain what information is needed and assist the family and older adult to create a Care Plan.
There are no plans to expand care services to those living outside Gwinnett County at this time.
What should I do if my parent gets worse after coming home?
You need to contact the appropriate healthcare professional when a new or worsening medical condition is noted. A Care Pro is not a substitute for medical evaluation. If you feel your parent is in a medical emergency situation, call 911.
If your parent is preparing to return home in Lawrenceville, Duluth, Snellville, or other communities served by the Norcross Home Instead office, don’t wait until the first day home to arrange for meals, transportation, and support for routine activities to cover the hours when family members can’t be there. Call (770) 972-2273 to find out what other non-medical home care supports may be available.
About the Author
Jonas Boutte is the owner of 101 Mobility of South Louisiana and serves customers throughout Lafayette and surrounding Acadiana communities. He helps families evaluate practical accessibility solutions, including stairlifts, vertical platform lifts, home elevators, ramps, and other mobility equipment based on the home and the person’s needs.
