Dakota Travel Nurse Home Care

Keeping home an option!

How Families and Caregivers Can Prepare for Hospital Discharge

DischargedResearch has shown that hospital pre-discharge planning that includes the help of families and caregivers can dramatically improve patients’ health, reduce readmissions and decrease healthcare costs. Whether the discharge is to home, a rehab facility, assisted living or a nursing home, patients, family caregivers and healthcare providers all play a significant role in maintaining a patient’s health after discharge. Unfortunately, the process and quality of discharge planning are not consistent throughout the healthcare system. If you are a caregiver, you must be the advocate for the patient and for yourself.

Who is responsible for discharge planning?Only a doctor can authorize a patient’s release from the hospital, but the process of discharge planning can be completed by a social worker, nurse, case manager or other person. The best scenario is when discharge planning involves a team.

The basics of a discharge plan and related discussions include:

  • Evaluation of the patient’s condition and likelihood of improvement by qualified personnel
  • Discussion with the patient and his caregiver about the types of care and equipment needed
  • Planning for transfer to another care facility, or to the home and what help the patient needs
  • Determining if family caregiver training or other support is needed
  • Referrals to home care agency and/or appropriate support organizations in the community
  • Scheduling follow-up appointments or tests before leaving the hospital
  • Reconciling pre-hospitalization medications with the post-discharge list for duplications, omissions or harmful side effects, and a discussion of who will administer medications.

Why is all-inclusive pre-discharge planning important?

Pre-discharge planning can decrease the chances that your loved one will be readmitted to the hospital, help in various aspects of recovery, ensure medications are prescribed and given correctly, and help prepare you to take over or get help for all the aspects of your loved one’s care. Patients are released from hospitals “quicker and sicker” than in the past, making it critical to prepare and arrange for good care after release.

The caregiver’s role in the discharge process

As a family caregiver, you are the “expert” on your loved one’s history. You know about the patient and about your own abilities to provide care in a safe home setting. During discharge discussion should include your ability to provide care. You must be upfront about physical and financial limitations, or other obligations such as a job or childcare that determine the time you have available. It is extremely important to tell hospital discharge staff about your limitations.

Some of the care your loved one needs might be quite complicated. Dakota Travel Nurse Home care will come to the hospital and evaluate special care needs, such as medication administration, wound care, post surgical care or catheter care, transferring someone from bed to chair or other needs you will need help with.

If your loved one has memory problems caused by Alzheimer’s disease, stroke, or another disorder, you will need to be a part of all discharge discussions. In addition to impaired memory, older people often have hearing or vision problems or are disoriented when they are in the hospital. Care instructions can be difficult to comprehend. They need you to be a second pair of eyes and ears.

Because people are in a hurry to leave the hospital or facility, it’s easy to forget what to ask. This link includes an extensive list of questions that you can print and take with you.

Help you may need at home

Some common care responsibilities you may have to handle or get help with for your family member after he or she returns home are:

  • Personal care: bathing, eating, dressing, toileting
  • Healthcare: medication management, physician’s appointments, physical therapy, wound treatment, injections, medical equipment and techniques
  • Emotional care: companionship, meaningful activities, conversation.
  • Household care: cooking, cleaning, laundry, shopping, other chores

You don’t have to handle all the care yourself! Community organizations and home care agencies like DTN Home Care can help with services such as transportation, meals, support groups, counseling, and respite care. The discharge planner should be familiar with these types of support, but if not, your local senior center or a private case manager could be helpful. Family and friends also might assist you with home care.

If you need to hire paid in-home help, you have some decisions to make. If hiring decisions are made in a hurry during hospital discharge, you might be handed a list of agencies to decide from, but often without additional information. If you know you will need this type of help, make time to research your options while your loved one is being cared for in the hospital.

You may have a choice between hiring an individual directly or going through a home care or home health care agency. If the help is “medically necessary,” i.e., prescribed by the doctor, and therefore paid for by Medicare, Medicaid or other insurance, they could determine covered agencies. Home care agencies take care of all the paperwork for taxes and salary, substitutes will be available if the worker is sick, and you may have access to a broader range of skills.

Discharge to a facility

If the patient requires discharge to a rehab facility or nursing home, transition planning should include continuity of care, patient’s current health and capabilities, medications review, and help selecting a suitable facility with available space. The sooner you can look at facilities and make a decision, the better. Once when my dad was unexpectedly being discharged from a hospital, I was told I had 4 hours to find a place for him and simply handed a list of numbers to call.

There are online sources of information that rate nursing homes and other facilities. Convenience is also a factor. You need to be able to easily get to the facility, but you may have to sacrifice your convenience for the sake of better quality care.

Paying for care after discharge

Insurance, including Medicare, does not pay for all services after a patient has been discharged from the hospital. However, if something is determined by the doctor to be “medically necessary” you may be able to get coverage for certain skilled care or equipment. Check directly with the hospital, your insurer or Medicare to find out what is covered and what you have to pay for. Keep records of your conversations.


Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. Dakota Travel Nurse Home Care personnel are qualified and available to be part of your pre-discharge team. Call us to arrange for an in-hospital, in-care-facility or in-home evaluation. You will be pleasantly surprised at the skilled and affordable care we can help to provide for you and your loved one.



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