Caregivers: Did you receive any discharge planning from the hospital or rehab facility?

[AmandaSingleton]

Hello:   I am curious if any of my fellow caregivers received instructions and assistance on how to care for a loved one at home after a hospital/rehab facility admission.  Studies are showing that if the caregiver is involved in the discharge planning, there can be a huge reduction in the likelihood that the patient will have to be readmitted.    I can share that over a period of years and numerous hospitalizations in my circle (including one last year where my husband was injured and unable to stand or walk for three months), this has been lacking in every experience I've had.  What have your experiences been?

[EricAZ]

I need to post a question about extending my mother's rehab hospital stay before Medicare throws her out on the street with no place to go on April 30. How do you post a question in this forum? I cannot find a place to "post" anywhere.

[JaneCares]

Hi there. I recommend that you find your way to the Facebook AARP Caregiving Group. There is voluminous and fast response there: https://www.facebook.com/groups/1353173708169053. It's not really Medicare per se, its the long term care system that we as Americans have chosen which puts the emphasis on family caring, which is so impractical... those public policies are 'throwing her out.' In any case, there should be discharge planners, or patient navigators who can help you plan a discharge. Does she no longer have a home to go to? Or she still is not independent? Will Medicare pay for some PT at home, and maybe an aide? Can you help her a little bit? Is there other family who can help as well? Or is she so weak that only assisted living will do? If she is low income enough then the state and federal monies will pay much or all. Please go to the facebook page and you'll find a lot of advice.

Good luck,

Jane 

[JaneCares]

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@AmandaSingleton wrote:

Hello:   I am curious if any of my fellow caregivers received instructions and assistance on how to care for a loved one at home after a hospital/rehab facility admission.  Studies are showing that if the caregiver is involved in the discharge planning, there can be a huge reduction in the likelihood that the patient will have to be readmitted.    I can share that over a period of years and numerous hospitalizations in my circle (including one last year where my husband was injured and unable to stand or walk for three months), this has been lacking in every experience I've had.  What have your experiences been?

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As a former hospital medical social worker, i can tell you that most social work departments in hospitals have been decimated since the 1980s and now most of the discharge planning work falls on RNs, Medical Assistants, social service assistants... and no one has time. Masters level social workers know the psychosocial reasons why people get depressed, and how to train family, or recruit friends to help, and how the disability system works... that knowledge is not available to families now.

Hospitals have to make money to stay open.  And by the way hospitals LOSE money if patients get readmitted too soon following a hospitalization: they get fined. There are readmission prevention committees in every hospital in the USA.

Jane

a former hospital discharge planner

[TimothyD134981]

Her discharge papers essentially only listed meds and generalities. home Health care has left recommended exercise sheets for her, but she’s isn’t going to follow thru. She’d rather blame me or her docs for her current conditions....

[AmandaSingleton]

Thank you for sharing your experiences TC Daniel.   Do you feel like any hospital readmissions could have been prevented with more training and better discharge follow-up?

I also wanted to mention for those of you who are caregiving and anticipate that your care partner may be hospitalized, there’s a new state law in about 40 states that may help with the discharge and aftercare tasks. The CARE (Caregiver Advise, Record, Enable) Act, known by different names in some states, helps family caregivers from the moment their loved ones go into the hospital to when they return home. 

If you are in one of the states that has passed the CARE Act, visit this link to download your free CARE Act wallet card, which gives you important information about the CARE Act to have handy when the time comes.  

[TimothyD134981]

Seems to me they just want her out and let the family figure it out. More $ for them if she comes back. 

The mental and physical issues she has has landed her back to a PASSR Level II rehab facility 35 miles away on Nov 1. Her PCP must have seen this as the right thing to do since he signed the papers for admission. Duration yet unknown.

i couldn’t make her do any social activities or take up a hobby at home. Zero interest sitting in the same rooms. Just deepening depression after being diagnosed with early Parkinson’s. 

Are they going to push her out and recommend the same cures? prob so. Get a walker/ rollator and everything will be fine. Go see the same docs for the same meds. like everybody has unlimited funds and time to drive across town seeking a better doc. problem is, they play out of the same rule book.

So to answer your question about hospital training, THEY are the experts, why are you asking me? Some patients will jump through every hoop to get better. All their recommendations have fallen on her deaf ears. 

I am relieved that she’s in rehab. Saw a different person two days after going in because of the change of environment. But the reality is it’s not going to get better when she comes home. same old vanilla.