Hospital Discharge Planning for Your Aging Parent

An emergency trip to the hospital, especially an unexpected one, can be overwhelming. As you and your loved one’s medical team focuses on their treatment during their time in the hospital, it’s also important to plan ahead and prepare for their care when it’s time to go home. 

While it’s great news that your loved one is ready and well-enough to return back to the comfort of their own home, a hospital discharge is more than just a simple pickup and drop-off. It's about ensuring your loved one has everything they need to thrive at home. Without a proper discharge plan, your loved one may face complications that could lead to re-hospitalization or decline in health.

Creating A Discharge Plan

As your loved one starts to heal, their doctors will assess them to determine whether discharge is safe and appropriate. They will consider several different factors, including their current condition and pain level, their ability to cope with lingering symptoms at home, and the amount of support they have from loved ones. When planning for your loved one’s discharge, there are some important questions to address to ensure a safe, successful transition back home.

Understanding Follow Up Care

Your loved one may be feeling well enough to go home, but they’ll probably still need medical care. You’ll want to know:

• Who to contact if there is a sudden change in their recovery 
• Who to contact if they have any questions as they recover at home
• When they need to meet with specialists or their primary care physician for follow-up appointments 
• Their list of medications, dosage, and when to take each one
• Any specific dietary restrictions

If this sounds like a lot, don’t worry! Print out this free downloadable guide and fill it out with your loved one’s doctor and care team before their discharge. It’s beneficial to have multiple people from your family present during this process, so everyone is aware of this information. If they can’t be present, make sure to send a digital copy of this document to everyone involved in taking care of your loved one. 

Home Safety & Preparedness

Next, you’ll want to determine if the place your loved one is moving to is safe and ready for their recovery. Consider any stairs, steps, or other mobility concerns inside the home and create a plan for how you will handle them. Will you have friends or family to assist you or will you need to hire professional help? Do you need to get any additional medical equipment at home?

Transportation 

Plan how you’ll be taking your loved one home from the hospital ahead of time. Will you or another member of your family be available at the time of discharge? Will your loved one need a wheelchair or a special vehicle to bring them home? Make sure they have comfortable clothes to travel home in! It is also important to plan how they will get to doctor’s appointments and check ups once you bring them home as well. 

Food & Meal Prep

Running errands while taking care of your loved one could be difficult. Make sure your and their fridge is stocked with all the food you’ll need, at least for a few days. Keep in mind any dietary restrictions that may be a part of their recovery. You may also want to meal prep in advance when possible, so you have time and energy to focus on making your loved one comfortable.

Many hospitals have discharge specialists on hand to make the process easier. As you prepare to leave the hospital, take notes about medication and other care tips recommended by the doctor, and get contact information for potential follow-ups. It’s likely that you’ll have questions after discharge, so you’ll need to know who to contact. 

Understanding Discharge Options

‍When an elderly loved one is discharged from the hospital, the transition back home or to another care facility can be overwhelming. If you’re feeling overwhelmed by all of the steps outlined as part of the discharge process, you do have other options available to you. There are several discharge options for older adults who have been in the hospital. 

Discharge Home With No Professional Care Services

‍If your loved one is stable, able to manage basic activities of daily living (ADLs), and can receive appropriate medical care at home, this might be the best option. This option is appropriate for those who have made a full recovery, or those with limited care needs that friends and family can help with. 

Discharge Home With Professional Home Health Care

‍In this case, the patient returns home, but health professionals continue to provide part-time services. This option can help patients return to a more comfortable environment without sacrificing care needs. Since in-home care is usually part-time, family members and friends will also need to play a role in ongoing care. Home health care can be a vital part of the recovery process. These services can include: 

• Skilled nursing care (e.g., wound care, medication management)
• Physical therapy to regain mobility
• Occupational therapy to help with daily activities like dressing or bathing
• Speech therapy for recovery of speech or swallowing function
• Personal care aides to help with non-medical tasks like meal preparation or housekeeping

Many home health agencies will work closely with your loved one’s healthcare providers to ensure continuity of care. Additionally, some patients might qualify for home health care covered by Medicare or other insurance programs, depending on the condition and doctor’s recommendations.

Discharge To A Skilled Nursing Facility For Short-Term Rehab

‍In a skilled nursing facility (SNF), nurses provide 24/7 care with doctor supervision. Moving to a SNF for short-term rehab may be a good option if your loved one is expected to make a full recovery, but currently needs intensive care. A skilled nursing facility can be an excellent choice for individuals who need:

• Rehabilitation after surgery, stroke, or an injury
• Around-the-clock nursing care for conditions like heart failure, COPD, or diabetes
• Assistance with mobility or activities of daily living (ADLs)
• Pain management that requires consistent monitoring

The goal in an SNF is often rehabilitation, with the aim of returning to a less intensive living situation (such as home or an assisted living facility) after a period of recovery. It's important to ask about insurance coverage for skilled nursing facilities, as some facilities accept Medicare, while others may only accept private insurance or private pay.

Discharge To A Skilled Nursing Facility For Long-Term Care

‍If your loved one is expected to need intensive care for an extended period of time, moving to a SNF can help them get the support they need in a more comfortable environment than the hospital. 

Discharge To Acute Inpatient Rehab

‍Acute inpatient rehabilitation is a high-intensity therapy program for patients who have experienced a severe health event, such as a stroke, injury, or surgery. The goal is to help patients regain their independence and basic functionality. Acute rehabilitation is often necessary for patients who have experienced significant changes in their physical or mental function. Acute rehabilitation is designed to help them regain important skills and function independently again. 

Discharge To A Long-Term Acute Care Hospital

‍A long-term acute care (LTAC) facility is a specialty-care hospital designed for patients with serious medical problems that require intense, special treatment for an extended period of time—usually 20 to 30 days. If your loved one has lost physical or mental capabilities, but is unlikely to regain full independence quickly, a long-term acute care hospital can provide the specific support they need. LTACs offer more individualized and resource-intensive care than a skilled nursing facility, nursing home, or acute rehabilitation facility. Patients are typically transferred to a long-term acute care hospital from the intensive care unit of a traditional hospital because they no longer require intensive diagnostic procedures offered by a traditional facility.

Discharge To Assisted Living

‍Assisted living facilities are a popular choice for older adults who need support with daily activities such as dressing, bathing, or medication management, but do not require the level of care provided in a skilled nursing facility. Assisted living facilities offer support with activities of daily living (ADLs) in a residential setting, but they do not provide the same level of medical care as a skilled nursing facility.Key features of assisted living facilities include:

• Personal care assistance with daily tasks
• Social and recreational activities to support emotional well-being
• Nutritional meals and support with dietary restrictions
• Transportation for medical appointments or social outings
• Medication management and assistance

Many assisted living facilities also have healthcare staff on-site for basic medical needs, but they may require residents to seek outside healthcare services for more complex conditions. Assisted living might be appropriate for seniors who are still fairly independent but need some help as they recover from a hospital stay or manage a chronic condition.To decide which option is best for you, take into consideration their ongoing medical needs, physical abilities, and overall well-being. The goal of each option is for your loved one to continue to get the care they need after they leave the hospital. Work with the hospital care team and patient advocates to explore all your options and see what makes sense for your family.

Appealing A Hospital Discharge

‍If you think your loved one is being discharged too early and needs to stay in the hospital longer, there are a few steps you can take. First, determine and communicate why you think your loved one should stay in the hospital. Reasons may include: 

• Your loved one is not healing from surgery as expected.
• They’ve acquired a hospital infection or other complications of surgery.
• Drug error, drug reaction, or complications from anesthesia.
• Your loved one cannot be transferred to your home safely.
• They need to be transferred to a skilled nursing center or rehab, but Medicare won’t pay unless you’ve been hospitalized for at least three days.
• The initial diagnostic code was incorrect and you require more care than was indicated.

It’s possible to appeal and delay the discharge process if you think it’s necessary. This is particularly important if your loved one will continue to require hospital-level care that you can’t provide. There are two ways to appeal your loved one’s discharge. One option is to file an official appeal through Medicare (if your loved one has it). This needs to be done as quickly as possible — usually by midnight on the same day. If you appeal in time, they will be able to stay in the hospital without cost until the decision is made. 

If your loved one does not have Medicare, you can also work with your hospital’s patient advocate to begin an appeal. In most instances, you can appeal on the day of discharge and stay in the hospital without financial liability until noon of the day after the hospital has received notification. Usually, the hospital can't force you to leave before a decision is reached. Make sure to request a second opinion or an in-hospital consultation with the appropriate specialist. And remind the nursing staff of their duty to advocate for your care. Get the nursing supervisor involved if needed.

If your loved one doesn’t have somewhere they can get the necessary care, you can also ask about the hospital’s "Safe Discharge" policy. Safe discharge means that a patient has appropriate care and support in place once they are discharged. There are strict definitions for determining if a discharge is safe, which can be presented to your insurance provider. 

Navigating the hospital discharge process for an elderly loved one can feel daunting, but with the right preparation and support, you can help them make a safe transition out of the hospital and ensure successful continued care for their recovery. From creating a discharge plan to arranging home adjustments and securing support services, each step can provide peace of mind for you and greater independence for them.