What is Discharge Planning?
Discharge planning involves planning for the care you will need after you are discharged from a health-care facility. The planning begins on the day that you are admitted. It involves the evaluation of and planning to meet your biological, psychological, social and spiritual needs once you are discharged. This planning may include involvement of family members or significant others as determined by your immediate and short term needs requirements. It may require the use of home health nurses or aides on a short or long term basis.Your health care team’s major objective is to help you either recover to your former state of health or help you cope with any limitations or disabilities that your illness or injury may present you with. Discharge planning is usually done by a Discharge Planning Nurse Specialist usually in conjunction with the Medical Social Worker.
If you have only been in the hospital a short while, you may not need to speak with a discharge planner. If you are being discharged and will require some type of help from a home health agency for such things as bathing, food preparation, feeding, dressing, medications, etc, the discharge planner or social worker will assess the family and see if they can deal with meeting those needs. If the family is willing and able to provide care, there is nothing more for the discharge planner to do. If, however, the discharge planner sees that the patient does not have any family or significant others who are able to help, arrangements will be made to provide that help through a community home health agency. These agencies can provide help with bathing, food preparation, wound care, catheter care, and other therapies. A social worker and a home health nurse will come out to the house right after discharge to do an initial evaluation, determine needs, and plan accordingly.
If you are being discharged to a rehabilitation, convalescent, or nursing home facility, the discharge planner/social worker will also work with you on finding the right place for you. The hospital frequently has affiliations with these kinds of facilities and naturally, these will be the ones they recommend first. Send your patient advocate ( family/friend/significant other) to look at the facility and also other facilities in your area. Make your choice carefully. The discharge planner will try and hurry you in the process. Don’t let them hurry you so much that you are unable to make a good decision. Get all your questions answered. And always remember, you are never a prisoner in any health care facility. You can always leave if you are not happy there…with or without your doctor’s consent.
My 80 year old mother fell down a flight on stairs in my home during a visit. She ultimately ended up in a rehab facility after sustaining a compression fracture of the spine and a fractured sternum. She spent 2 weeks in intensive physical therapy in preparation for discharge back to my home. She had been smart enough to have purchased long term care years prior to the accident. That policy covered $100 per day towards a nursing aid to care for her in the home. We gave the discharge coordinator at the rehab facility all the information about the home health care insurance policy. By the time we brought my mother back to the house upon discharge, the nursing aide was sitting in the driveway waiting for us. And the hospital bed, which had been ordered by the discharge coordinator the day before, had already been delivered and set up in our family room. The discharge process was simple thanks to the help of the discharge coordinator.