THE BLOG

Care Transition From Hospital To Home

01/22/2016 07:22 am ET | Updated Jan 28, 2016
  • Anita Kamiel, RN, MPS Founder/owner of David York Home Healthcare Agency, Registered Nurse with advanced degrees in Gerontological Administration

Returning home from the hospital can be stressful for the older adult for many reasons. In most cases, the patient has been 100 percent dependent on hospital staff and the shift to life at home with less help can be cause for anxiety. While it is a relief to be going home, they may be afraid of how they will manage alone. The trauma of the illness coupled with the care transition can be frightening to both the patient and their loved ones. Their children might be afraid to let them suddenly fend for themselves and they may be too proud to admit to needing the additional help. Fortunately, hospitals do not discharge anyone without the discharge planning social worker ensuring that arrangements are made.

Whether it was a fall that has left them with reduced mobility or just recuperating from surgery, assistance with moving a patient and catering to their needs is essential for preventing additional injuries. Unfortunately, one in five Medicare recipients is re-admitted to the hospital within 30 days of discharge. A hospital re-admission is costly physically, emotionally and financially and a trend is long underway to avoid this at all cost. Proper planning and education can help.

The discharge planner works with the family to ensure continuity of care in terms of any home care, treatments and therapies. While many of the elderly can be independent with respect to a certain amount of care, they may need assistance with some of the activities of daily living such as bathing and dressing. A home health aide is great for the transitional stage. You can hire one for more hours at the beginning and lessen them once the patient is stronger and more independent.

The family and the patient must be fully involved in the discharge planning process. It is crucial that there be a point person in the family for care during the transfer who has knowledge of actual transportation arrangements and any home care set in place. They must have a list of all medications and dosages and the reason for each as well as an understanding of any possible side effects. They must be knowledgeable of any symptoms that are warning signs of anything more serious in order to be able to contact the doctor before a situation gets serious. The patient must realize that their regular doctor may not be aware or have access to the medical information pertaining to their hospital stay. The patient must update the doctor and transmit any medical records pertaining to the stay. Finally, the patient and their family must make the recommended follow-up appointments with specialists in order to treat any chronic condition uncovered or the one which led to the hospitalization. They may also need a registered nurse or physical therapist for some follow-up care.

It is important to consider the physical landscape upon returning home. Places like the bathroom and kitchen will need elder-proofing to make a safe living environment, taking into account new physical limitations. Certain items make home care easier. The installation of a raised toilet seat in the bathroom can prove essential. A portable toilet containing a bucket, grab-rails and raised seat in the bedroom may be necessary and the use of adult diapers can help alleviate accidents. When taking a shower or bath, make sure the levers or knobs are clearly labeled and elongated for easy use and rubber mats and shower chairs will help prevent falls. For the bedroom, a light switch or lamp near the bed will make illuminating a dark room easy. Make sure area rugs are removed as they are tripping hazards. Handrails on stairs should be checked and, if you use the stairs multiple times in the day, consider adding a stair-lift. This would also be a good time to check that the smoke and carbon monoxide detectors in the home are in good working order. Lastly, in lieu of changing any locks, a lock box commonly used by real estate agents is a handy item. These are boxes that hold a key and go around the handle of the front door. They are opened via a combination lock which the patient can give to whomever they wish so they need not be bothered to get up and answer the door while they are recuperating. It is also an affordable safety device should someone who normally would not have a key need immediate emergency access into the senior citizen's home.

Transitioning from the hospital to home can seem daunting, but consulting the right professionals can make the process seamless and as stress-free as possible.

Anita Kamiel, R.N, M.P.S. is the founder and owner of David York Home Healthcare Agency and is fully acquainted with all factors related to eldercare services and the latest guidelines for seniors. Thirty years ago, she realized the need for affordable, quality home health aide services provided and supervised by caring individuals. You can contact her at 718.376.7755 or at www.davidyorkagency.com. David York Agency is also on Facebook, Twitter, Google+ and LinkedIn.

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