Dr. You

Leaving a hospital or transitioning between care settings can be challenging. This section provides information and tips to help you navigate care transitions safely and effectively. It emphasizes patient preferences, effective communication, and coordinated care to facilitate a smoother recovery and achieve better outcomes.

Patient Story – (The story is true; the patient’s and provider’s names have been changed.)

Diana, an elderly patient, was discharged from Suburban Medical Center (SMC) to her home after treatment. Shortly after discharge, Diana received a text message from SMC’s care team via SMC’s health platform. The outreach allowed Mary to communicate that she was unable to fill her prescribed anticoagulant medication. Without the medicine, Diana was at high risk for potentially life-threatening complications.

The SBC team quickly identified Diana’s medication access problem and consulted with her discharge physician. The team provided Diana with a coupon for a free 30-day supply of the anticoagulant. They also scheduled a follow-up appointment with Diana’s doctor to ensure continuity of care.

Diana gave permission for her daughter, Linda, to be included in the text message communications. Involving Linda in communication strengthened the support system for Diana’s recovery at home. Diana’s case demonstrates how a patient’s proactive participation during a transition from one care setting to another can prevent potentially life-threatening situations and ensure a safer transition from hospital to home.

Why Care Transitions Matter

The quality of transitional care management has a direct impact on a patient’s overall well-being. Studies show that a significant percentage of older adults experience medication errors after hospital discharge, and many Medicare patients are readmitted to the hospital within 30 days of their discharge (Agency for Healthcare Research and Quality (AHRQ). Effective transitions lead to safer recoveries, fewer medication errors, reduced hospital readmissions, lower healthcare costs, and enhanced patient satisfaction.

Your Right to Appeal a Hospital or Nursing Home Discharge

Hospitals and nursing homes cannot discharge a patient to an unsafe care setting without risking severe financial and professional consequences. If you do not feel ready to leave the hospital, take the following steps:

• Discuss with your doctor and discharge planner: Explain why you believe you require additional time and that discharge may not be safe.
• Contact Your Insurance Company or Medicare/Medicaid: Ask about their appeal process.
• Understand the Hospital’s Review Process: The hospital must inform you of the steps it is taking to review your case.

Important: You have the right to appeal the discharge decision. If your appeal is denied, you may be responsible for additional hospital expenses.

Creating a Transition Care Plan

A transition and coordinated care plan is crucial for a seamless and safe transition to a new care setting, and it is vital for improving healthcare outcomes, safety, and efficiency (Institute of Medicine). Work with your physician and discharge planner to develop a plan that includes:

• Assessing Patient Needs and Goals: What are your priorities for recovery and ongoing care?
• Communicating Clinical Information: Ensure that all providers have the necessary medical details.
• Communicating Patient Preferences: Share your wishes and priorities with the care team.
• Developing a Healthcare Transition Plan: Outline the steps for a seamless transition.
• Establishing Responsibilities: Clearly define who is responsible for each aspect of your care.
• Linking to Community Services: Connect to resources such as transportation or meal delivery services.
• Scheduling Follow-Up Appointments: Arrange appointments with doctors and specialists.
• Ensuring Equipment and Supplies: Making sure you have the necessary medical equipment and supplies.
• Arranging Transportation: Coordinate travel to appointments or other healthcare settings.
• Providing Support: Assisting you in addressing any challenges you may encounter in your new environment.
• Monitoring and Adjusting: Tracking your progress and adjusting the plan as necessary.

Common Obstacles to Effective Care Transitions

• Fragmented Healthcare System: Recognize that the healthcare system can be complex, thereby increasing the risk of errors.
• Communication Gaps: Processes between providers may not always be seamless, resulting in miscommunication.
• Confusion About Referrals: Understand why you are referred to a specialist or a particular facility, your rights, and your insurance coverage.
• Information Incompleteness: Ensure that your primary doctor and specialists share complete and accurate information about your medical history and care.

Transitioning From Hospital to Home, Rehab, or Nursing Home

Hospital discharge planning should include:

• Evaluation by qualified staff
• Discussions with you and your caregivers
• Planning for care in the new setting
• Determining needed support
• Referrals to support services.
• Arrangements for follow-up care

Before Leaving the Hospital

Upon leaving the hospital, you should receive discharge instructions. Unfortunately, they can be confusing, and sometimes even contradict what your doctor has told you. Here’s what you need to do before leaving the hospital:

• Medication List: Obtain a complete list of all medications, dosages, and instructions.
• Medical Equipment: Inquire about necessary equipment, such as walkers or oxygen supplies.
• Warning Signs: Recognize potential warning signs and understand the specific steps to take in response.
• Activity Readiness: Discuss which activities you are ready to resume, such as bathing and dressing.
• Follow-Up Appointments: Schedule follow-up appointments with your healthcare providers.
• Special Skills: Learn any specialized skills required for your care, such as wound care.
• Medical Records: Obtain copies of your medical records. Consider using a Personal Health Record (PHR) to manage your health information.
• Arrange for Support: Know where you are going and who will be responsible for your care.
• Insurance Coverage: Understand your insurance coverage and associated financial obligations.
• Discharge Instructions: Ensure you receive clear and understandable discharge instructions, a summary of your status, and copies of your medical records as soon as possible.

Choosing a Rehab Facility or Nursing Home

If you are going to a rehab facility or nursing home, consider these questions:

• Expected Length of Stay: How long will I typically need to stay here?
• Facility Recommendations: Do you recommend a facility, and if so, what are the reasons?
• Language and Culture Support: Will I be cared for by someone who speaks my language and understands my cultural background?
• Dietary Needs: Can the facility accommodate my dietary requirements?
• Experience with Your Condition: Does the facility have experience treating patients with my condition?
• Staff-to-Patient Ratio: What is the ratio of caregiving staff to patients during the day and at night?
• Visiting Hours: Are family and friends welcome at any time throughout the day?
• Location: Is the location convenient for family and friends?

Tip: Check facility ratings at Medicare.gov.

Tip: Have someone you trust visit the facility to assess the cleanliness and overall happiness of the residents.

Returning Home with Home Care

If you are returning home and need home care:

• Initial Contact: Have initial contact with your home care provider before leaving the hospital.
• Remote Monitoring: Discuss remote monitoring options with your healthcare provider.
• 24/7 Advice: Obtain a phone number from your doctor for 24/7 advice and support.

Tip: If you are an older adult or care for one, consider contacting your local Agency on Aging and Disability resources to learn about available assistance tailored to your specific situation. You can call 800-677-1116 to locate your local office or visit their website at www.eldercare.gov.

If you have a caregiver, it is extremely important that you discuss their willingness and ability to provide the care you need with your discharge planners. Your caregiver(s) may have their own physical, financial, or other limitations, such as a full-time job or limited transportation, which can both affect their ability to provide care.

Support for Caregivers

If you have a caregiver, discuss their willingness and ability to provide care with your discharge planners.  Ensure they receive any necessary training, such as wound management. There may even be special training that they need to ensure you receive the right support. Several types of care that require additional training include wound care and management, feeding tube insertion, catheter care, ventilator procedures, and transferring a person from a bed to a chair.

Paying for In-Home Help

If you need in-home help, decide between hiring someone directly or using an agency. Consider the responsibilities and potential liabilities of hiring privately. If you choose to hire someone directly, you may have a more personal relationship and pay a slightly lower rate. However, you may also be responsible for managing the paperwork related to salary and taxes, as well as any liability for accidents or other issues. Not to mention, it will be much harder to find a good replacement if your caregiver is no longer able to help you.  Your insurance or Medicare/Medicaid may limit your choices if home care is deemed medically necessary.

Community Resources

Explore community organizations that provide assistance with transportation, meals, support groups, counseling, and financial aid.

Alzheimer’s Transitions

Moving can be particularly stressful for individuals with Alzheimer’s disease. To minimize stress:

• Plan: Discuss living arrangements while the person is able.
• Research Facilities: Visit potential facilities.
• Visit with the Person: Decide whether to bring the person during visits.
• Speak with the Administrator: Discuss the individual’s background, needs, and preferences.
• Familiar Surroundings: Make the room feel familiar by incorporating your favorite items and furniture.
• Photos: Add photos of loved ones and label them for staff.
• Avoid Valuables: Do not leave valuable items.
• Share Routines: Inform staff of the person’s routines and schedule activities during their optimal time of day.
• Engage with Staff: Have staff interact with the new resident while the family leaves quietly.
• Visit Often: Visit frequently and encourage others to do so.

Keep a list of these guidelines and questions with you and review them with your discharge planner to ensure a smooth and well-managed transition to healthcare.