Elderly patients are too frequently readmitted to the hospital within a short time of being discharged.  This problem has come to the attention of the healthcare system and entities that pay for the care, which has led to more research about the nature of these readmissions and what might be done to prevent them.

Some of the primary problems that have been identified in the discharge process are the decentralized nature of the process (i.e. different providers involved between care at home and hospital, orders by different physicians, etc.) and as related, the communication during this critical time.  Of course, it is a vulnerable time even with the best planning, due to the likelihood that the patient is weakened and various concerns may arise such as infection or complications.

Here are five steps you can take as a family member to enhance safety after discharge:

1. Get written discharge instructions and make sure that you (or whoever is the caregiver/advocate), the patient and the provider contact (physician or discharge planner from the hospital) review them together.  Ask questions about anything you do not understand.  Pay special attention to medicines.  What is each medicine for, and does it replace a previous medication?  This is the time (if not already done) to bring up any concerns about new medications/changes.

2. Gain a clear picture of expectations.  What is the short and long-term prognosis?  How will the patient be (weakness, abilities, needs) upon discharge?

3. Plan for someone to be with the patient round-the-clock for minimum 24-48 hours after the hospital stay (if returning home, and possibly even if being discharged to a skilled nursing or assisted living facility).  This is the most critical time for safety and problems.  Also, if you plan to be with your loved one (or some family member does), you may still want to hire a home health aide to be there as well, in case multiple things need to be done at once (i.e. picking up new medicines, while being there to help your loved one in and out of bed, grocery shopping, laundry, etc.) or you cannot handle the physical assistance that may be needed.

4. Make a list of key contacts for discharge help.  What home health company have you chosen?  Do you know when they will come out and who to contact if there is a problem?  (Do the same for medical equipment or any other follow up care.)

5. Update the patient’s records.  Make sure records and information from the hospital stay gets over to his/her providers (new list of medications, diagnoses etc.) and update any records you keep.

When a loved one goes to the hospital, the learning curve is steep and you may feel overwhelmed by all the decisions you need to make in a short period of time.  In order to help you learn what is available and guide you through the process, a personal advocate or geriatric care manager can be invaluable.

Click here to watch Shannon Martin’s Webinar, Mom’s in the Hospital-What Now?.

Shannon Martin, M.S.W., CMC, is Director of Communications at Aging Wisely, LLC(http://www.agingwisely.com), a professional care management and patient advocacy organization and EasyLiving, Inc. (www.easylivingfl.com), a licensed home care agency, in Clearwater, FL.  Shannon created a course on “Eldercare” as adjunct professor at Eckerd College in St. Petersburg, FL.  Prior in her career, Shannon served as social services director and admissions coordinator in an assisted living/skilled nursing facility and worked as a social worker and volunteer coordinator for a large hospice.

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