Benefits of Preparing a Discharge Plan for Hospitalized Seniors

What is post discharge planning? Is it the same as pre-discharge planning?
They are not exactly the same, but may have some similarities between them.

Why do we care? Why is it important? Does it make any difference? Is it a difficult process? What resources are out there?

During my decades of practice in geriatrics, I came across numerous scenarios of people needing information on post discharge planning. While seniors and families were helped immensely by Social Services, resources at the hospital where people were discharged either to their own homes or to senior living facilities or communities with home health, home care, hospice or rehabilitation, there were a lot of questions and issues I had to figure out, plan, solve, and help proactively with forward thinking.

Here is a checklist of information you may want to carry with you, as a senior or family member plan the next journey for their beloved:

  1. Have you had contact with the home health, home care, rehabilitation, hospice as suggested by the hospital?
  2. Is your insurance covering these services and if so, how much? What is your part of payment?
  3. Have you kept track of the progress as charted by home health, home care, hospice, rehabilitation?
  4. Are you recuperating as planned?
  5. Have your milestones been mapped, correctly?
  6. What were your goals vs. the organizations or companies providing ancillary care?
  7. Have you had follow up lab-work done at the appropriate time post discharge?
  8. How has your nutrition been? Is it right on target as supposed to be or has it become an issue?
  9. Has your primary doctor kept in touch with you during, pre and post hospitalization at the hospital or a facility?
  10. When are you supposed to follow-up with the doctors, health professionals, dentists or outpatient health services?
  11. Are you in need of extra help or are you alone?
  12. Do you have tools like telephone, safety installations, safety chains or bracelets with your condition inscribed on them?
  13. Are you in contact with local senior resources and services like the area agency on aging?
  14. Are you struggling with poly-pharmacy (multiple pharmacies / duplicate prescriptions)?
  15. Is the medication adequate and appropriate?
  16. Have you asked your pharmacist about new drug-drug interactions, wrong combinations or incomplete prescriptions ?
  17. Who manages your care at home or facility or community?
  18. Do you think you are in a safe place with safe hands and feel secure, safe and comfortable?
  19. Are you ready to make some life decisions like advance directives if not completed previously, or do you feel more confused, in pain or down and depressed?
  20. Are you the same person before, during and after hospitalization? Do you feel you have declined, aged, become more confused or just feeling more tired lately??

There are many more, and we will explore those in the coming weeks ….

Hope this will help you and your beloved senior about how frail a senior’s health is and could be.

Post discharge planning does not end here, as according to research the risk for re-hospitalizations, the simultaneous presence of multiple chronic diseases or conditions in a patient, and mortalities are higher in the days to months after a recent hospitalization. Quality of life is a key denominator of the social, medical, community, economic, and environmental determinants of life.


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