When you or a loved one are discharged, that is usually a good thing. It may even be cause for celebration. However, there are still many issues you or a loved one may still face upon discharge. Facing these issues on your own can create a great deal of stress and feel like an uphill battle.

These are some of the questions and issues that Next Step for Seniors handles and makes sure that everything is taken care of once you or your loved one is discharged:

Discharge from Hospital to Rehab

Is there any documentation that needs to be filled out? If so, has it been given to the facility?

  • Next Step for Seniors handles and makes sure that everything is taken care of once you or your loved one is discharged from the hospital and transferred to a rehab facility. Specifically, we make sure all the orders, medications, face sheet and medical files are forward to the rehab facility in advance of the arrival.

From Rehabilitation Facility to Assisted Living or Home

Transitioning a loved one home or to an assisted living facility from a rehabilitation facility can be a stressful time for families. There are a lot of moving parts involved. Not only is it emotionally stressful, but if not handled effectively, the transition home or even to an assisted living facility can lead to exacerbation of health issues.

When is the person leaving?

Sometimes you only get a few days’ notice when you or your love one are being discharged. With such little lead time, it is often difficult to make all the necessary arrangements, such as: has the medication list been forwarded to the facility, has the facility received that medication list, has transportation been arranged, has all the durable medical equipment been ordered, delivered and set-up, has the room as the assisted living facility been confirmed… to just name a few.

  • Next Step for Seniors can step in and help you make the appropriate arrangements so you or your loved one is not left out in the cold.

Consider appealing the discharge.

If you think your loved one is being discharged too soon or to an unsafe community situation, speak up! By law, the rehab facility must let you know how to appeal and explain what will happen. Appeals can take up to a week, but sometime can occur sooner. If the appeal is denied, then insurance will not pay for those additional days. Also, you or your family member might have to leave the facility immediately or private pay for the continued stay.

Where is the person going?

If you know where you or your loved are going, make sure the other facility knows when you will be arriving.

  • Have they received all the necessary documentation, including Face Sheets and medication information?
  • Next Step for Seniors can do all the follow-up and follow-through on your behalf so the discharge process and relocation process goes smoothly.

Who is handling the transportation? Why type of transportation is needed?

  • The rehab facility usually will not transport you or your loved one to another facility.
  • Maybe the assisted living facility will provide transportation to their facility. Who is coordinating that effort?
  • In the rare cases where neither the rehab or assisted living facility will provide transportation, then it is up to you or your love to one to arrange private transportation. When using a transportation company to a private home, can the transportation company transfer you or your loved into the house and to a safe spot inside the home (not just dump them in the entryway)?
  • If the discharge is happening after hours or close to the end of the business day, is the assisted living facility aware of and ready to handle the late arrival. Is someone available at the door to assist in the arrival?
  • If a family member is handling the transfer and transportation themselves, are they able to transfer and get the person where they need to go safely?
  • Next Step for Seniors can help coordinate all the necessary transportation needs. Note: Next Step for Seniors does not directly transport patients to any locations.

If therapy is needed, have the appropriate orders been forwarded to and received by the assisted living facility.

  • Next Step for Seniors can ensure the orders been forwarded to and received by the assisted living facility.

If going home after discharge from a rehab facility and need therapy, who is setting that up and who will be providing it? What physical therapy and occupational therapy is being recommended? Have the outside therapists been notified in advance so therapy can start as soon as possible?

  • Next Step for Seniors can ensure the companies have been notified in advance and are scheduled for their first therapy session.
  • Should problems with a particular provider occur once you are home, Next Step For Seniors can help arrange for a different company to come in and provide the service.

If you or your love one are going home after being discharged, is the home ready to handle the needs?

  • Next Step for Seniors can do an in-home safety assessment to insure you know what needs to be done prior to you or your loved one returning home.
  • In consultation with the physical therapist and occupational therapist, has a list of equipment been put together that may be needed to make the home safer. This may include a hospital bed, a bedside frame, toilet commode, or the installation of grab bars in the bathroom.
  • What other durable medical equipment may be needed?
    • wheelchairs or walker
    • lift
  • What other supplies may be needed? This may include incontinence products, monitoring equipment or setting up a food delivery service.
    • oxygen, (will your rehab facility loan you an oxygen tank if needed to go home with?)
    • medications from the facility
    • check with therapists and nurses on anything else that will be needed
  • Next Step for Seniors can do all the follow-up and follow-through on these sorts of issue.

If any home modifications need to be done, have they been done by the time you or your loved one arrives post-discharge? Next Step For Seniors can help you thoroughly evaluate and assess the home ahead of time.

  • Take a look around you or your loved one’s home with a critical eye. Make sure it can accommodate any functional limitations and is maximized for barrier-free care. Take measurements at home – especially important are doorways, beds, tubs, showers and toilets. Find out what equipment will be covered by insurance and what you are expected to pay for. Arrange for large equipment – like beds – to be delivered ahead of the discharge day.

Do you or your loved one have a plan to manage medications after discharge?

  • If your loved one is cognitively or physically unable to track and fill medication prescriptions, medications can be sorted and arranged in weekly boxes by a designated family member or nurse care manager. Caregivers can then cue their client to take the medications at the correct time. For less impaired clients, there are automated medication dispensers or pill reminder services.
  • If going to a facility, are the admission people aware they are arriving, who have you spoken to, do they know as well, if the room is ready. If at mealtime, will there be a room tray available for them (if known may be able to order prior to arrival)

Final Note: How a Seniors Advocate can support and help you in this area.

I know this information can be a bit overwhelming, but a Senior Advocate, like myself, can simplify it and assist you and your loved one in making the transition from discharge to home or assisted living as stress-free as possible. If you have questions or wish to start the process of working with a seniors advocate, I would be happy to meet with you for a complimentary consultation regarding your particular situation. Call me at 303 -888-4575.