Discharge Planning from Acute Care to Home or Residential Care

Discharge planning is the number one reason Patient Pathways is called by families and loved ones. We are asked to intervene when the hospital staff say that loved ones will be discharged today or tomorrow – and families know that the situation is just not safe or suitable. Often discharge planning (or lack of) becomes a case of crisis management. If you or your loved one is going to face issues in being at home safely, please read on… and if you are overwhelmed or not getting the answers you need, call us as soon as you possibly can in during the hospital stay. Situations are much easier to mediate when there are several days before the potential discharge home.

Every person, at all ages or ability needs to think about and plan for discharge from hospital, no matter how minor the admission or procedure. The older you or your loved one is, the more serious the illness or surgery, the more discharge planning is necessary.

For those who are over 65, for those with serious health issues (any organ failure at any level), those with mobility issues, and those with memory issues, discharge planning is essential.

For a simple, uncomplicated discharge after a minor procedure and surgery for those in relatively good health and under the age of 65:

  1. Who is picking you up?
  2. Who will be staying with you for at least 24 hours? Your support person is there to help you with small tasks and being with you until you are steady on your feet, and also to watch for reactions to the anesthetic or pain medications and be able to call 911 if needed.

For minor to moderate treatments and procedures with instructions to limit activities AND for those over the age of 65:

  1. Who is picking you up?
  2. Who will be staying with you for at least 48 hours? Older adults can have very significant reactions to pain killers and anesthetics – even if you’ve never had a reaction before. Your support person is there to help you with small tasks and being with you until you are steady on your feet, but also to watch for reactions to the anesthetic or pain medications and be able to call 911 if needed.
  3. They should watch for:
    • Unusual weakness, sleepiness, or not ‘bouncing-back’ as expected.
    • Excessive bleeding, if you’ve had surgery.
    • Disorientation or delusions. These are SERIOUS signs of infection for seniors.

For all PLANNED major treatments and surgeries for people of all ages:

  1. Meals: Is someone able to prepare meals for you? If not, plan ahead and fill the fridge and freezer. Meal services are good for a few days but they become boring quickly. Meals on Wheels or Better Meals are relatively inexpensive but are not terribly nutritious and lack fresh fruit and vegetables. Think about grocery delivery and set this up prior to hospitalization. If cost is not an issue, several companies now come into your home to prepare meals.
  2. Mobility: will you have crutches or a walker? Have you been well-trained in using these aides and are you confident on carpets? Prior to hospitalization make sure paths are clear and extra furniture and clutter have been moved out of the way and set up bathrooms with the appropriate transfer equipment and raised toilet set (if necessary). Note that most of this equipment can be ‘borrowed” from local Red Crosses but you need a signed requisition from an Occupational Therapist.
  3. Personal care assistance: Need for Home Health assistance is assessed IN HOSPITAL and not pre-arranged. Government SUBSIDIZED assistance is NOT free for anyone and is based on your previous year’s income. These services extremely limited and are ONLY provided for those who are having issues with Activities of Daily Living (ADLs) and have no one else who can help: bathing, dressing, transferring to and from bed or toilet, feeding. Generally, you will have 15 to 20 minutes of care twice per day.

Important note: Home Health does NOT provide:

  • Meal preparation: they will heat and put out a previously prepared meal.
  • ANY housework of any kind.

The government program, Better at Home, does allow for light housekeeping for those over the age of 65. If you are frail and want to live at home as long as possible, call your local community health or seniors center and ask for help in applying for this program. The waiting list (last checked) was over a year and because of this, is not an option for those who will have short term physical limitations.

For those who are not limited to government services, pre-plan PRIVATE personal assistance and home support services prior to hospitalization. Look for agencies who:

  1. Will provide consistent caregivers (not a new one every day)
  2. Who are bonded and train their caregivers.
  3. Can provide customized services including personal care, light-housekeeping, laundry, shopping and small errands.

For all UNPLANNED hospitalizations, major treatments and surgeries for people of all ages OR when treatments or surgeries became complicated and the road to recovery long:

Your loved one has likely been very ill or seriously injured: as the substitute decision maker (SDM) or Representative (see our Advance Care Planning tab), this is really when you are needed most. This is likely going to be a marathon and not a sprint. You will need to keep your wits about you and NEVER assume that your loved one will only be discharged when they are ready. Discharges are based on hospital need for beds and not the doctor or nurses’ projections.

Unplanned and ill-prepared discharges are the cause of significant stress on patients and families. These discharges often result in patient injury (and extreme cases, death), caregiver injury and burnout, and frequent re-hospitalizations.

It is ESSENTIAL that you start talking about discharge planning early (even when the healthcare professionals say “it’s too soon for this discussion”). Be proactively involved in discussions with the occupational therapy and physiotherapy teams who are the leaders of most discharge planning. Discuss with them:

  • The physical layout at home and challenges you foresee.
  • Any equipment that might be needed and where you can get it (for free through the Red Cross: you will need a signed requisition from the Occupational Therapist).

Complicated discharge planning, including a team meeting should be requested when:

  • You do not feel your loved one should come home. You will have to provide compelling reasons. Family IS expected to help support loved ones both physically and financially at home and they are expected to make the home a safe environment. Residential care (assisted living and long-term or extended care) are last-resort options for healthcare providers as there simply are not enough of these beds available.
  • You foresee issues with safety and need for equipment including a bed and lift equipment.
  • You foresee the need for home support and what will be provided by community services and what you might want to enhance with private home care services.
  • Transport home will be an issue.

Talk to the unit Patient Care Coordinator (PCC), Unit Manager, or Social Worker to arrange a meeting with the following in attendance. Get a written plan. Take notes.

  1. Wherever possible, the patient.
  2. Substitute Decision Maker(s) and/or Representative.
  3. If possible an ‘educated witness’ from the family’s side – anyone who can take notes and remain calm and cool in a crowded room of people talking quickly. (Patient Pathways provides this service.)
  4. Community Liaison (represents and arranges in-home care)
  5. Most Responsible Physician – MRP (in teaching hospitals, ask specifically for the MRP and not the lead Resident)
  6. Occupational Therapist
  7. Physiotherapist
  8. And all other relevant healthcare professionals.

If you feel you are not being heard and being pushed toward an unsafe discharge, immediately ask to speak to these people in this order:

  • Patient Pathways (info@patientpathways.ca or 604-440-6795)
  • The Unit Manager
  • Patient Care Quality Office for the hospital (this contact information should be by most elevators): be aware that most PCQOs will not get back to you for at least 48 hours and not on evenings or weekends. The more concerned you are, the more messages you should leave and let the office know the urgency.
  • Director of Nursing
  • Director of Medicine.

Transfer to Residential Care:

If this is deemed the only option, as the Substitute Decision Maker or Representative there is LITTLE choice as to where your loved one will be placed under the FIRST AVAILABLE APPROPRIATE BED (FAB) policy UNLESS you are willing to place your loved one in a PRIVATE pay facility. Once your loved one is placed in a subsidized bed (please see the What is Residential Care blog) you will have the right to request they are put on a waitlist for a bed in the facility of your choosing (anywhere in the province).

In conclusion:

Get yourself or your loved one out of the hospital and to the best place as safely as possible. Being at home is often, though not always, the best place. Hospitals are dirty, dangerous, noisy places. Just get home properly with as many resources as possible. Planning ahead means a much safer journey to recovery.

Better at Home
First Appropriate Bed Policy

For uncomplicated discharges, the Patient Pathways librarian recommends the following links:

HealthLink BC: Discharge Planning

HealthLink BC: Hospital Discharge Checklist

Heart & Stroke: Stroke – Leaving the Hospital

Heart & Stroke: Heart – Coming Home

Most hospitals and care facilities will have a booklet or pamphlet about hospital discharge. Ask your care team.