Hospital to Home: Plan for a Smooth Transition - n4a

HOSPITALTO HOmEPlan for aSmooth Transition

Returning home from a hospital stay can result in unexpectedchallenges for many seniors. Finding themselves back athome after a hospital stay, many older adults struggle to managetheir medications and make follow-up doctor’s appointments aswell as obtain the physical assistance and in-home support theymay require, at least on a temporary basis. As a result, many olderadults do not successfully make the transition home well and endup returning to the hospital. In fact, one in five Medicare patientsare readmitted to a hospital within 30 days after discharge. Studieshave shown that nearly half of the readmissions are linked to socialproblems and lack of access to community resources.You can help ensure that you or your loved one makes a successfultransition home from the hospital if you start planning for yourhospital visit before you are admitted for a planned procedure or forunexpected visits to start planning for discharge the day ofadmission. Planning goes a long way to help patients address thequestions that arise during the discharge process and make a safeand smooth return home.Where will you go? Your own home? A familymember’s home? A rehab facility?Will you need help getting to follow-up doctor’sappointments? To the pharmacy?Will you need help with meal preparation? Bathing?Who will assist you? Your family member?A home health aide?How long will you need assistance?This guide is meant to help stimulate thinkingabout the answers to these and other questions. It isintended for older adults and their family and friends whowill help them transition successfully from a hospital back home.You can learn about transitioning home and more from the United HospitalFund’s Next Step in Care (www.nextstepincare.org). Additionally, you can learnabout community resources that may be of assistance with your transition home from your localArea Agency on Aging. The Eldercare Locator (www.eldercare.gov) can direct you to an agencyin your area.

PrE-HOSPITALIf you have a planned admission, and youknow that you will be staying in thehospital for at least one night for an elective(non-emergency) surgery, tests or specialprocedures, planning takes several steps.What do you need to do before you areadmitted? What do you need to bring?You will likely get a packet of pre-admissionpapers. Ask for this packet if the hospital doesnot offer it. The packet will have basicinformation about:■ Tests you need before admission■ Where to go on the day of admission andwhat time to arrive■ Hospital policies, such as visiting hours■ Information about paymentHow longwill I be inthe hospital?HOSPITAL TEAm – Maintainregular communication with your “hospitalteam” – this group can include doctors,nurses, social workers, your caregiver(s)and other health professionals at thehospital. If your primary care provider isnot part of your hospital team, make surethat someone on the team or a familymember is communicating with him or her.EmErgEncy! Not all trips to thehospital are planned. If you do not haveenough time to plan and must go straightto the Emergency Room, be sure to bringany medications you are taking and healthinsurance information. It is a good idea tohave an Emergency Room kit similar to thehospital kit.Hospital KitLeading up to your hospital admission, youshould create a kit to take to the hospital.Here are some items to include:■ Insurance information and identificationcard■ List of your doctors, with contactinformation■ Emergency contact numbers■ Test reports, lab results and copies ofrecent X-rays■ Names and dosages of all yourmedications. Besides prescription drugs,be sure to include vitamins, herbals,laxatives and other over-the-counterproducts. You can use a “MedicationManagement Form” to assist you.■ List of any allergies■ Health Care Proxy and AdvanceDirectives. You should prepare thesepapers whether or not you are going tothe hospital, but if you have not donethis, the hospital can give youinformation.■ Other items to bring: eyeglasses,dentures, hearing aids and toiletries.■ DO NOT bring jewelry, money or othervaluable items!

POST-HOSPITALHospital stays are often very short. Assoon as a doctor says you are “medicallystable,” the hospital will want to discharge you.Depending on the condition, patients oftentransition from the hospital to home or to ashort-term rehabilitation program in a nursinghome. This section focuses on importantconsiderations when you are heading homefrom the hospital or a rehab program.Make sure you or your family caregiver talks toa discharge planner, someone at the hospitalwho helps plan a smooth transition home.There are a lot of details to work out and thesooner you start the better. Here are someimportant issues to keep in mind:your HomeMake sure to order all the needed equipmentand supplies. A member of your hospital teamcan help you with this task. If you are eligiblefor home care agency services, find out what theagency provides and what you must get on yourown. Here are some good questions to ask:■ Will I need a hospital bed, shower chair,commode, oxygen supply or otherequipment? If so, where do I get these items?■ What supplies do I need? This may bediapers, disposable gloves and skin careitems. Where do I get these?■ Will my insurance pay for the equipmentand supplies?What type of care will Ineed when I return home?Additionally, your home should be comfortableand safe, and a good place for care. Ask thehospital team if you need to do anything specialto get ready. This might be to:■ Make room for a hospital bed or other largeequipment■ Move out items that can cause falls, such asarea rugs and electric cords (a good idea inany event)■ Create a comfortable space for a familymember or friend who might be stayingwith you for a few days■ Find a place for important information,such as a bulletin board, notebook or adrawerHealth care TasksYou and/or a caregiver will likely do certaintasks as part of your care. What will you beable to do by yourself? What will you needhelp with? It is important that you and/oryour caregiver know how to do these taskssafely and properly. You and any caregiversyou might have should try to learn as much aspossible while you are still in the hospital. Youcan do this by watching hospital staff as theydo these tasks and asking them to watch asyou try these tasks yourself.Sometimes, hospital staff will not teach thesetasks until the day you leave the hospital. Thismay not be a good time to learn if you feelrushed or overwhelmed. Learn what you canand ask who to call if you have questions athome. You might be told to call someonefrom the hospital, a home care nurse or otherhealth care professional.If you are a caregiver, speak up if you are afraidof doing certain tasks (such as wound care) orcannot help with personal hygiene (likebathing or changing adult diapers). The

hospital team needs to know what tasks youcan and cannot do so they can help you planfor any needed help.medication managementIt is important to betaking the rightmedications, at theright time and in theright amount. Hereare some questionsto ask that can helpyou do this job well:■ What new medications will I take? Howlong will I take them?■ Should these medications be taken withmeals? At certain times each day?■ Do they have any side effects?■ Can new medications be taken with thoseI was taking prior to being admitted?■ Are any new medications listed in the“Medication Management Form,” alongwith other prescriptions, over-the-countermedications, vitamins and herbalsupplements?■ Do I get these medications from mypharmacy or the hospital?■ Will my insurance pay for these medications?If not, are there generic alternatives?■ For more useful tips, read the EldercareLocator guide, “Managing YourMedicines.”fOOd — Ask if there are certain foodsyou can or cannot eat. This might includespecific foods such as milk or meat, orgeneral types of food, such as very soft foodor liquids. If you need special foods, try tobuy them ahead of time when it is easier toshop.Know Who to call andWhat to doYou may have a lot of questions during thefirst few days at home. Make sure you havephone numbers for people on the hospitalteam, as well as any home care agencyinvolved with your care and a listing ofcommunity services you may need.Make sure you know what to do for your care.This includes knowing:■ Are there any symptoms that you mustreport right away, such as fever, intensepain, or shortness of breath? If you noticethese symptoms, who do you call and whatshould you do?■ Are there limits or restrictions on what yourcan do? For example, you might not be ableto drive, take a bath, lift heavy things orwalk up or down stairs.■ Is it safe to be alone? How often should Iask a family member or friend to check in?community resourcesMany communities have resources that canhelp you and your caregiver, such as: helpwith transportation for medicalappointments, home-delivered meals,medication management assistance, choreservices, in-home support services, as well ascaregiver support and respite (time awayfrom caregiving) To find out about the localresources in your community, contact yourlocal Area Agency on Aging, you can getconnected with them by calling the EldercareLocator at 800.677.1116 or visitwww.eldercare.gov.

fOr cArEgIvErSIf you are a caregiver, bringing your family member home can be overwhelming. There are somany things to do and remember. Having a good plan is the first step. Try to focus on whatmust be done immediately. The rest can wait. Be honest about your limitations, whether theyrelate to your own health, your job or other responsibilities. The Next Step in Care guide“What Do I Need as a Family Caregiver?” is a good basis for a self-assessment of your needs.Ask other family members, friends and community agencies for assistance.USEFUL RESOURCESEldercare Locator offers a variety of brochures with information for older adults and caregivers.Visit www.eldercare.gov (Resources tab) to view the “Managing Your Medicines” brochurementioned in this publication, and more.Next Step in Care offers many resources for patients and caregivers. Visitwww.nextstepincare.org (For Caregivers section) to view the “Medication Management Form”and “What Do I Need as a Family Caregiver” guide mentioned in this publication, and more.800.677.1116www.eldercare.govwww.facebook.com/eldercarelocatorThe Eldercare Locator is the first step to finding resources for olderadults in any U.S. community and a free national service funded by agrant from the U.S. Administration on Aging (AoA). The EldercareLocator is administered by the National Association of Area Agencieson Aging (n4a).www.nextstepincare.orgThe United Hospital Fund’s Next Step in Care website has guides forfamily caregivers on many aspects of transitions, including medicationmanagement, discharge checklists, hospice and palliative care, andmany others. The guides are free and available in English, Spanish,Chinese, and Russian.This publication was supported, in part, by a grant, No. 90AM3206, from the Administration on Aging, U.S. Department of Healthand Human Services. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings andconclusions. Therefore, points of view or opinions do not necessarily represent official Administration on Aging policy.