DISCHARGE PLANNING

The Discharge Planning Department ensures that the individual's medical, psychosocial, and environmental needs are integrated with the family, social and community support systems available to them. This department addresses all types of continuing care needs including: adoption, community support groups, durable medical equipment requests, financial and legal assistance, home health referrals, protective agencies, and nursing home transfers.

For more information about Discharge Planning at PAH, please call 814-938-1609.

In general, the basics of a discharge plan are:

Evaluation of the patient by qualified personnel
Discussion with the patient or his representative
Planning for homecoming or transfer to another care facility
Determining whether caregiver training or other support is needed
Referrals to a home care agency and/or appropriate support organizations in the community
Arranging for follow-up appointments or tests

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. It also should include information on whether the patient’s condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation and chores; and possibly referral to home care services.

Some Basic Questions for Caregivers to Ask

Questions about the illness:

• What is it and what can I expect?
• What should I watch out for?
• Will we get home care and will a nurse or therapist come to our home to work with my relative? • Who pays for this service?
• How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-• up medical appointments?
• Have I been given information either verbally or in writing that I understand and can refer to?
• Do we need special instructions because my relative has Alzheimerʼs or memory loss?

What kind of care is needed?

• Bathing
• Dressing
• Eating (are there diet restrictions, e.g., soft foods only? Certain foods not allowed?)
• Personal hygiene
• Grooming
• Toileting
• Transfer (moving from bed to chair)
• Mobility (includes walking)
• Medications
• Managing symptoms (e.g., pain or nausea)
• Special equipment
• Coordinating the patients’ medical care
• Transportation
• Household chores
• Taking care of finances

Questions when my relative is being discharged to the home:*

• Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment?
• Are there stairs?
• Will we need a ramp, handrails, grab bars?
• Are hazards such as area rugs and electric cords out of the way?
• Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment?
• Who pays for these items?
• Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?
• Will insurance/Medicare/Medicaid pay for these?
• Do I need to hire additional help?

Questions about training:

• Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment?
• Have I been trained in transfer skills and preventing falls?
• Do I know how to turn someone in bed so he or she doesn’t get bedsores?
• Who will train me?
• When will they train me?
• Can I begin the training in the hospital?

Questions when discharge is to a rehab facility or nursing home:

• How long is my relative expected to remain in the facility?
• Who will select the facility?
• Have I checked online resources such as www.Medicare.gov for ratings?
• Is the facility clean, well kept, quiet, a comfortable temperature?
• Does the facility have experience working with families of my culture/language?
• Does the staff speak our language?
• Is the food culturally appropriate?
• Is the building safe (smoke detectors, sprinkler system, marked exits)?
• Is the location convenient? Do I have transportation to get there?

Questions about medications:

• Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken?
• How will we know that the medicine is effective?
• Will this medicine interact with other medications? prescription and nonprescription? or herbal preparations that my relative is taking now?
• Should this medicine be taken with food? Are there any foods or beverages to avoid?
• Can this medicine be chewed, crushed, dissolved, or mixed with other medicines?
• What possible problems might I experience with the medicine? At what point should I report these problems?
• Will the insurance program pay for this medicine? Is there a less expensive alternative?
• Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling?

Questions about follow-up care:

• What health professionals will my family member need to see?
• Have these appointments been made? If not, whom should I call to make these appointments?
• Where will the appointment be? In an office, at home, somewhere else?
• What transportation arrangements need to be made?
• How will our regular doctor learn what happened in the hospital or rehab facility?
• Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?

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