Senior Brochure In Order (Lexington).pdf - Home Instead Senior Care

A Family Caregiver’s Guide 

To Discharge Planning 

2 nd Edition_ 

“Plan ahead” 

“Take a team approach” 

“Listen to your loved one”

A Family Caregiver’s Guide 

To Discharge Planning 

An elder loved one or disabled person is entering a hospital or nursing 

facility. Whether this is a planned event or due to an emergency, it is never 

an easy time. Usually, the condition of your loved one will improve to the 

point where they are able to return home. The transition back to a home 

environment is also not easy. With a little planning, however, there is a great 

deal that you can do to simplify the process. 

Who this guide is for 

This guide is intended for any caregiver who is helping an elderly loved one 

or disabled person return home from a medical facility.To simplify language 

within this guide, the patient is referred to as either “he” or “she” though the 

information is not geared towards a specific gender. 

What is discharge planning 

Discharge planning includes all the steps taken to ensure that your loved 

one makes a safe transition from a hospital or nursing facility back to their 

home environment (a home can be a single family residence, an in-law 

apartment, senior living community or an assisted living facility). Discharge 

planning is not a single meeting but rather a sequence of events. With the 

right team of people, the goal is to assess what your loved one’s needs are 

and develop a plan that will bring him home safely. 

When should discharge planning begin 

As soon as possible. The key is to plan ahead. Sometimes, there will be 

circumstances that make it impractical to begin thinking about a 

discharge plan. If your loved one has suffered some sort of trauma or if you 

have no idea how long she will be at a hospital, you may need to wait for 

additional information before you can start thinking about next steps. 

In other situations, you may know right away that the person you are caring 

for will be ready to return home within a few days. In this scenario, you 

should begin thinking about the discharge plan right away. Fortunately, 

there are people to help. 

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Who is involved 

Discharge planning may involve some or all of the following people: 

• Patient 

• Family Caregiver or Friend* 

• Physician 

• Social Worker 

• Case Manager/Discharge planner 

• Nurse(s) 

• Other medical staff such as physical or occupational therapy 

• Local Ombudsman 

* Try to designate one person from the family who can act as a central 

point of contact for the hospital or nursing facility. 

What to expect from a discharge planner 

A discharge planner will help provide a plan that will safely transfer your 

loved one from a medical facility to a home environment. They can also 

put you in touch with community resources and provide information that 

will make it easier to care for your loved one at home. 

What not to expect from a discharge planner 

If your loved one is going to another facility, it is best to research this facility 

on your own. Also, when scheduling a discharge meeting, remember that 

most discharge meetings will happen Monday – Friday, 9am – 5pm. 

So where do I start 

Step 1. Learn about the facility. When your loved one enters a hospital or 

nursing home, ask to speak with the person who will be managing their 

discharge plan. Ask what you should bring to the initial meeting (this may 

include a healthcare proxy, power of attorney, insurance cards and 

financial information). 

Step 2. Gather background information. Prepare for your discharge 

meeting by writing down important facts about your loved one’s condition 

prior to when they entered the hospital. Some questions that may be 

addressed include: What was your loved one’s condition like before they 

entered the medical facility How was their appetite How was their shortterm 

and long-term memory How was their temperament Answering these 

questions will give staff members a baseline by which to gauge your loved 

one’s progress. 

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Step 3. Assess needs. For the near term, can your loved one be left 

alone Who will manage their finances When your loved one returns 

home, who will manage the grocery shopping and cleaning It is a good 

idea to make a list of all the things that you feel will be necessary to assist 

your loved one for the 3 months following their return home. Go through the 

list and determine which things you and other family members can handle 

and which things you will need help with. Remember to be flexible. Over 

time, new things may be added to your list and some will be eliminated. 

Step 4. What new skills will you need to learn Sometimes, caregivers 

may need to learn how to assist their loves ones in new and unfamiliar ways. 

Potential assistance could include: assistance with transfers, how to oversee 

medications or how to help with a catheter bag. If you need to learn about 

these things, make an appointment with the facility staff prior to the 

discharge day. This will avoid having a training session that is rushed. It will 

also give you a chance to ask questions and become more comfortable 

with your new responsibilities. 

Step 5. Meet with facility staff. Your discharge planning meeting is the 

opportunity to answer most of your questions. This guide contains 14 of the 

most common questions that you may have regarding a patient 

discharge. If your loved one is in a skilled nursing facility, try to schedule this 

meeting at least one week prior to discharge to allow for any additional 

work that needs to be done. Stays in the hospital are typically shorter but it 

is ideal if you can plan at least a couple of days in advance. In either case, 

be sure to get the names of appropriate staff that you will meet with on the 

day of discharge and ask about the transportation arrangements to get 

your loved one home. 

Step 6. Final planning. 

• Get dates for follow up appointments 

• Coordinate home care services that are not covered by 

Medicare/Medicaid 

• Ensure that appropriate safety measures have been taken at home 

(see list) 

• Ask the discharge planner if suitable transportation can be provided to 

get your loved one home safely (Medicare may or may not cover a 

transport home) 

• Be prepared to be flexible! 

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14 Questions to ask in a discharge planning meeting 

1. Update on current condition and anticipated recovery _____ 

2. Expected discharge date and time _____ 

3. Name of doctor(s) who may authorize the discharge _____ 

4. Complete list of medications and instructions _____ 

5. Other necessary services (i.e. Home Care) _____ 

6 What equipment is needed (i.e. shower seats, grab bars, 

hospital bed) _____ 

7. If leaving a Nursing Center and there is rehabilitation, 

will a rehab specialist be able to make a home assessment _____ 

8. Exercise routine _____ 

9. Danger signs and how to deal with them _____ 

10. Follow-up appointments needed after discharge _____ 

11. A contact person for more advice, information or help _____ 

12. What services will be sent home (i.e. Visiting Nurse) _____ 

13. Dates for when the Visiting Nurse or other services will come _____ 

14. Nutritional suggestions (include dietary restrictions) _____ 

14 Planning steps to bring your loved one home 

(check those that are applicable) 

1. Throw away expired food and restock the refrigerator _____ 

2. Dispose of old and expired medications (including over the 

counter meds)_____ 

3. Complete medication list and medication pick up or delivery _____ 

4. Set up pill box (see if the pharmacist can do this) _____ 

5. A plan to ensure meds are being taken properly _____ 

6. Remove throw rugs that cause falls _____ 

7. Shower seat and non slip floor mat _____ 

8. Hand held shower head _____ 

9. Grab bars _____ 

10. Raised toilet seat _____ 

11. Night light _____ 

12. Test smoke & carbon monoxide detectors _____ 

13. Winchester Hospital Lifeline (781) 756-4752 _____ 

14. Transportation to get your loved one home_____ 

Questions 

Check List 

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What sort of costs can I expect 

Medicare is our country’s health insurance program for most people age 

65 or older. The program helps with the cost of health care, but it does not 

cover all medical expenses associated with non-medical care. For 

additional information, the Federal Government prints a guide titled 

Medicare & You that explains in detail what benefits seniors are eligible for. 

For a copy of this guide or for more information: 

• Call 1-800-MEDICARE (1-800-633-4227) 

• Visit www.medicare.gov on the web 

Many people are surprised to learn that Medicare will not cover all of the 

costs associated with taking care of someone at home. It is a good idea to 

ask your discharge planner what is and isn’t covered with respect to your 

loved one’s care. Also keep in mind that the Visiting Nurse Association is a 

good resource but these services do not last indefinitely. 

Local Offices on Aging. 

Your local office on aging is an excellent resource for elders, families, 

caregivers and health care professionals. The offices below provide a 

variety of services including information and referral and ombudsman 

programs which advocate for people with loved ones in nursing facilities. 

Local Aging Office Phone Number Towns Served 

Minuteman Senior 

Services 

(888) 222-6171 

www.minutemansenior.org 

Arlington, Lexington, 

Winchester, Woburn 

Springwell Elder 

Services 

(617) 926-4100 

www.springwell.com 

Belmont 

Mystic Valley ELder 

Services 

(781) 324-7705 

www.mves.org 

Medford 

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Do you need transportation home for a 

patient being discharged 

Contact: 

Home Instead Senior Care’s 

Home Safe Service 

$60 for transportation home and up to 3 hours 

assistance getting settled. 

781-402-0060 

Serving: Arlington, Belmont, Lexington, 

Medford, Winchester and Woburn 

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Important tips 

While your loved one is trying to get better, your job is to think about next 

steps. Being discharged does not mean that your loved one is cured of 

whatever they entered the hospital for in the first place. Don’t try to do 

everything at once. Avoid making decisions under pressure. Take time to 

consult with people you trust and think through decisions. 

1. Listen to your loved one. Always remember who this discharge plan 

is for. To the extent possible, include your loved one in the decisions you are 

making on their behalf. Even if they have difficulty giving input, they will 

appreciate knowing that efforts were made to consider their feelings. 

2. Get a notebook. Try to get one which has a calendar and an inside 

sleeve where you can file papers. Use this to keep track of important 

names, numbers and dates. Also, use your notebook to keep a record of 

important conversations with health care professionals. 

3. Be realistic about how much you can do. Taking on additional 

responsibilities can be stressful. Do not try to tackle too much at once. 

Assess how much you and other family members will be able to help after 

your loved one comes home. If you are not comfortable helping with 

intimate personal hygiene or other aspects of the care plan, be vocal 

about saying so. Remember to be realistic! 

Disclaimer 

Home Instead Senior Care and its franchisees do not assume legal liability 

or responsibility for the accuracy, completeness, or usefulness of any 

information, contained in this pamphlet. 

For information on home care services, please call: 

Home Instead Senior Care 

5 Militia Drive 

Lexington, MA 02421 

781-402-0060 

www.homeinstead.com/404 

jack.cross@homeinstead.com 

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Notes 

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Notes 

Key Contacts:__________________________ _ 

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Important Dates:_________________________ 

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781-402-0060 

www.homeinstead.com/404 

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For information on home care services, please call: 




781.402.0060 

www.homeinstead.com/404

Senior Brochure In Order (Lexington).pdf - Home Instead Senior Care

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