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The Post Discharge Checklist: 5 Important Steps

Two weeks ago, Andrew’s elderly father suffered a heart attack. After undergoing bypass surgery, he is being released to return home. While his father is eager to get out of the hospital and back to the comfort of home, Andrew is hesitant about the transition. There are new medications to take, new specialists to see, and his father requires more assistance with daily activities than he did prior to the heart attack. While he’s pleased that his father is well enough to go home, Andrew’s not quite sure how to handle caregiving after the hospital discharge.

Andrew’s situation is a common one for caregivers the world over. Life can change significantly after a hospitalization, and while care may seem coordinated and well-organized in the hospital, caregivers can be left with a lot of questions about what to do after returning home. The list of five steps below can be used as a guide to help caregivers and their loved ones feel prepared for the smoothest possible transition back home.

1. Make a Post-Discharge Care Plan 
Before even signing the forms to head out the door, caregivers can help ease the transition by asking hospital staff for help in developing a post-discharge care plan. This plan will typically lay out the required care, such as new dietary restrictions or medications, any special equipment needed, follow-up care including in-home care or therapies, any changes in the patient’s care needs and functioning, and what support the caregiver needs to provide the new level of care. While you probably won’t know how to lay out a care plan on your own, social workers, nurses, and physicians at the hospital can help get the plan together and direct you to resources that may be helpful in carrying out the post-discharge care for your loved one.

2. Reconcile Medications 
The number of individuals that leave the hospital with medication errors is startling—up to 40% of seniors* have been found to leave the hospital with incorrect dosages, or new prescriptions that interact with current medications. (See FCA’s fact sheet, Hospital Discharge Planning: A Guide for Families and Caregivers and its cited sources.) Certain medication interactions can be potentially life-threatening, making the need to “reconcile,” or compare and confirm medications, very important. To complete this step, work with a physician or nurse to compare a complete medication list from before the hospitalization with the new list at discharge. Look carefully at any medications that have been added or stopped, as well as confirming the dosages and schedules of the medications. In addition to the physician or nurse, the pharmacist can be a great resource in making sure there aren’t any harmful drug interactions.

3. Schedule Follow-Up Visits 
As a caregiver, it’s not always easy to convince those you care for that they need to go to the doctor, especially after a stay in the hospital. However, follow-up visits as part of post-discharge care are critical to monitor a patient’s progress, adjust care activities or medications, and reduce the risk of re-hospitalization. Be sure to schedule follow-up visits as recommended by your loved one’s primary care physician and hospital providers. If you know that your loved one may be less than thrilled to head back to a doctor, try asking physicians and nurses to help stress the importance of getting checked up to avoid landing back in the hospital. The outside perspective may help in encouraging follow-up care. The discharging physician may also approve a home health nurse, physical therapist, or home health aide for more support and monitoring when the patient goes home. Before discharge, you should know who is coming to the home, when, and whether you need to arrange the appointments or if they will be calling you.

4. Ask Questions 
As a family caregiver, you probably know the ins and outs of caring for your loved one better than anyone else, which is why you have every right to ask questions of care providers before and after leaving the hospital. Perhaps you’re uncomfortable with the idea of needing to transfer your father from the bed to a wheelchair, or are unsure of what signs to look for that may signal a relapse of their condition. Don’t hesitate to ask nurses, doctors, and others involved in discharge care about any hesitations or concerns that you may have. In fact, you may find that asking questions helps hospital staff link you to resources or training that can help with the post-discharge care process. If you feel your ability to provide care after discharge will be limited by work or family obligations, your own health, or finances, ask the hospital staff about options for more in-home help or out-of-home care if needed.

5. Seek Support 

Caring for a loved one after hospital discharge can be an overwhelming process. While senior hospitalizations can be a hurdle filled with challenges, there is help. Resources ranging from social workers to support groups and home care providers can help you feel properly informed and prepared to take on post-discharge care. It is likely that you will face some difficulties, so try keeping the name and phone number of a contact person with you for easy reference, and don’t hesitate to ask questions that will surely come up throughout your care providing experience. For more information on post-discharge hospital care, read the FCA Hospital Discharge Planning: A Guide for Families and Caregivers fact sheet mentioned above, or take a look at the United Hospital Fund’s information page on Next Step In Care.