Whether it is helping our clients and their families through recovery from a serious illness or surgery, providing ongoing support to those with disabilities, or easing the end-of-life transition, our team’s job is to provide exceptional home care families can count on. We also feel a responsibility to educate and advocate for our clients and their families as they navigate healthcare so they can make informed decisions confidently.
The Realities of Hospital Discharge is a three-part series, covering three options after a hospitalization: home healthcare, rehabilitation centers and hospice. (Read Part 1.) Continuing our exploration of the hospital discharge process, Part 2 delves into medication management when discharged to a rehabilitation center and then home.
Managing Post-Discharge Medications Isn’t as Straightforward as It Seems
You’d think that filling and managing medication prescriptions would be one of the easiest parts about being discharged from the hospital and the recovery process. But a medication regimen isn’t as straightforward as it seems.
Why? There are a few reasons:
- A hospitalist sees hospitalized patients, not the primary care physicians (PCPs) who usually know their patients better. What a PCP knows, a hospitalist might not.
- The hospital and the PCP could be two different corporate entities with different relationships with different pharmaceutical companies. What brand a PCP prescribes, a hospital might prescribe another.
- What is prescribed at hospital discharge and intended for a rehab center staff to manage and administer isn’t always practical or possible in a home environment.
Unfortunately, it’s not uncommon for patients to be discharged with medications that may not be necessary, are difficult to afford, or even conflict with existing prescriptions. This can lead to issues ranging from financial strain to health risks.
To help lessen these challenges, a patient and/or their families should PAUSE. Pause before filling prescriptions post discharge and ask questions. Three questions to ask are:
- Why is the medication being prescribed?
- How long should the medication be taken?
- Is this the best regimen for the patient?
Communicate openly with the PCP (the hospitalist and PCP don’t always communicate with each other) and bring an up-to-date list of current medications to hospital admission. These simple steps can help ensure that only the most essential and appropriate medications are prescribed, reducing the risk of errors and adverse effects with other medications, not to mention make it easier on the patient and family who’ll eventually oversee the regimen.
The Hospital Starts Making a Discharge Plan Upon Admission. So Should You.
For hospitals, a discharge nurse is already planning for a patient’s discharge following admission. You should too.
Early and clear communication about the discharge plan makes a significant difference in a patient’s recovery. Yet, many patients, especially the elderly, are caught off guard by the sudden news of their discharge—sometimes the day of. A day is simply not enough time for the patient or family to prepare for discharge to either a rehab center or home. A center needs to be chosen, the home prepared, and all that entails. It’s especially stressful on family members who are charged with care but have families and work responsibilities of their own.
If you’re working with Medicare, you should know that more of the responsibility for post discharge care is falling on family members. Yet Medicare is failing to adequately prepare family for the situation.
Care coordinators, like those at Focus Healthcare, fill the gap Medicare often leaves. If we’re involved at the time of admission, we can make the process so much smoother. We can keep lines of communication open between hospital staff, patients and families. This ensures everyone involved is well-prepared for the patient’s transition from hospital to rehabilitation center and/or home.
Setting Care Goals and Managing Medications
When a patient is discharged from the hospital, the goal for many families is to just get their loved one home and comfortable. That’s important, but there is more involved for a successful recovery, which takes setting and meeting specific goals.
One of the key conversations in the discharge process regards setting specific care goals for the patient, such as managing chronic conditions like dehydration or malnutrition, and encouraging physical activity. These goals should be tailored to the patient’s individual needs, ensuring a smooth transition to home care.
Coordination is also essential when it comes to managing medication regimens, particularly in cases where patients are transitioning to rehab or home care. For example, adjusting insulin administration to fit a home environment can prevent complications and reduce the likelihood of readmission. It’s important for patients and their families to understand that effective medication management is about more than just taking the right pills—it’s about ensuring that those medications fit into the patient’s overall care plan.
When choosing a care coordinator or home care service provider, make sure they have the staff and capacity to handle all your needs, not just a few.
Focus Healthcare has the BEYOND THE ER™ (BETER) Care Package designed for transitions from planned or unplanned hospitalizations to rehab facilities to home or hospice.
Our tapered 30-day plan, starting with 24/7 care for 1 week and gradually decreasing the hours per day each week for 4 weeks, increases the likelihood of success at home.
This plan includes:
- Nursing oversight and support on a weekly basis
- Personal care services
- Assistance with prescribed physical therapy treatments
- Transportation to follow up appointments
- Light housekeeping (laundry and other household chores)
- Cleaning out and restocking the refrigerator if needed
- Coordination of care with your choice of home health or hospice provider
Hospital Discharge is a Time to Be Proactive
Being proactive is critical to a successful hospital discharge, and it starts at admission. Patients and/or their family members should ask questions, understand the treatment plans and be involved in every step of the discharge process.
The tricky part is knowing which questions to ask because we simply don’t know what we don’t know. All patients’ care goals are different, but pulling in a care coordinator right off the bat puts the patient and family in a better position to reach those unique goals and ensures the right questions are asked, and more importantly, answered.
In the end, improving medication management and communication during the discharge process empowers patients to take control of their health and ensure that they have the support they need to recover safely.
For a free in-home evaluation or to discuss any of our in-home health services, call (816) 628-5303 or contact us.
