Care in Hospital and Discharge Planning
Being admitted to hospital can seem like you’ve landed on a completely different planet. This isn’t health care, this is ‘crisis care’. The turnover of nurses and doctors is overwhelming. There are a lot of things happening at the nursing station that you are likely not even aware of. You will get whisked off for tests but you don’t know what they’re looking for. You will receive new medications that no one has talked to you about. And, you might be discharged before you are ready. As a care partner you need to learn a new language overnight.
This is an introduction to how to navigate this overwhelming new world.
Everywhere you go…
Pack your Communication Skills
Ask about “Risk versus Benefit” for all treatments and surgeries.
Be as clear and concise as possible about your symptoms and concerns (tell the truth and don't leave anything out - even if it's embarrassing.)
Be assertive about letting your health team know about any Advance Care Planning wishes and documents. Give your nurse a copy of your Representation Agreement and ask that it be put at the front of your chart. You will likely have to remind them it’s there and what it’s for.
Wherever possible, have someone with you.
Understand Care in Hospital
A special note about your primary care practitioner and your hospital care:
It is surprising for most patients that their family practitioner has no influence on admission to hospital; except for small rural hospitals, they likely do not have admitting privileges (so they can’t write orders while the patient is in hospital; and, likely won’t even be informed the patient was admitted to hospital).
Upon discharge, call the office to make a follow-up appointment.
Ask for information about your loved-one
Read, Who is who in the healthcare zoo.
The number one things I hear from families is that they have no idea who to talk to and who is responsible for what. The faces and the names change every shift. As a navigator with a client in hospital, finding out who to talk to about the patient’s condition and plan of care, takes a massive amount of time. I am more often hanging around the nurses’ station to catch the right person than I do in my client’s room.
If you are the care partner/substitute decision maker/Representative, it’s important to know that you can call the nursing unit!
As quickly as possible, find out who the key healthcare professionals are on the hospital unit where your loved one is receiving care.
Get the phone number or extension for the nursing unit.
Ask questions and use your notebook.
If you are the Representative, you do have a right to ask for updates and discharge status.
As the patient or their care partner, this is the most important time to use your notebook!
Find out where you are (the nursing unit name) and ask for the phone number or extension.
The best times to call:
• 10 am to noon
• 2 pm to 4 pm
• 10 pm to midnight
• 4 am to 6 am.
Discharge Planning!
Going home after an unplanned admission to hospital can be the most complex and dangerous transition of care. While home is often best for recovery, the transition should be planned and prepared for.
When it comes to discharge planning… No news is definitely not good news. Assume that discharge will happen sooner than expected and maybe before the patient or loved-ones are ready for.
Be aware that doctors have little influence on when a discharge will take place! Once the patient is ‘medically stable’, discharge can take place.
It is important to find out who is responsible for discharge planning! Find out who will make the decision (bed control, a unit manager, social worker, occupational therapist, etc.) about the planned discharge date and keep following up.
Be proactive. Plan Ahead. Assume the worst. Follow up!
Be aware of the ‘Home First’ policy!
Except in the most serious cases of advanced cognitive decline, where a significant safety risk has been determined, all hospitals are mandated to try and send the patient home with home support before a transfer to assisted living or long-term care will be considered. Only if the patient ‘fails’ to manage at home will residential care be considered.
Financial Considerations
If you will need long-term support at home, there are serious limitations in public home care and significant costs in hiring private home care.
The BC Ministry of Health – and the Seniors Advocate of BC – fully expect families to liquidate and use assets, including reverse mortgages on their homes to fund home care and residential care costs, whether they are public-subsidized or private.
This can be a massive strain and burden on families – and a very big concern for surviving spouses who may have many more years to live. Discussions should take place long before a crisis, and your Enduring Power of Attorney made aware of financial decisions you would and would not want to make.
Will you need home care support?
What other support will you need to go home? Often the Occupational Therapist is the best person to discuss your home situation. The Social Worker is often the best resource if additional care or long-term care need to be considered. See Chapter 8.5, Understanding Home Care.[CJ1]
Will you need any equipment?
Ask about any special equipment you will need (crutches, cane, walker, wheelchair, shower bench, hospital bed, commode) and where you can rent or buy it. If the need for the equipment is temporary and you can’t afford it, ask your Occupational Therapist to sign a requisition to get an equipment loan from your local Red Cross (usually available for a maximum of three months).
Where do you find it?
How can you get it installed?
Will a wheelchair fit through doorways? (An often overlooked and serious problem.)
Is your home appropriate for mobilization & equipment?
Can you get to the bathroom? (The ability to have a bath or shower is not a barrier to going home as sponge baths are considered appropriate.)
Would a commode beside the bed be possible?
Can the bed be moved to a more appropriate space for care – such as the living room or dining room?
Is there room for a ‘lift’ over and around the bed?
Are there stairs that can’t be avoided? Could they be retrofitted with a stair lift (there are grants available)?
When will you be assessed for home care?
What will you do until these services are put in place?
Do you need to consider private home care services in the meantime?
When will home care start?
What care needs to be provided in the meantime?
Does any training of family caregivers need to be done before discharge?
What if home is not the appropriate choice?
● Is a rehabilitation unit an option for extra time to recover and get stronger?
● What does long-term care look like and how long will that process take?
● Do you need to go into respite care?
In most areas, there is a profound lack of respite and long-term care beds. You will need to prove the need and why you can’t go home with home care support.
When to ask for a “Discharge Planning Meeting.”
If you are concerned that your loved-one simply can’t go home, or if you will need significant support and you are not getting the answers you need, ask for a Discharge Planning Meeting. The unit Social Worker or Occupational Therapist are often the best people to put together the meeting but some hospitals and units have a Community Liaison, or a Community Nurse Liaison (CNL). Ask for the following healthcare professionals to attend:
Occupational therapist
Physiotherapist
Most Responsible Physician (MRP) for your care
The community care liaison.
Come to the meeting with a witness and a clear list of concerns, such as:
Your loved-one has had multiple admissions and is not coping at home.
Public-subsidized home care services will not be enough (usually due to safety) and private home care is not an affordable option.
The physical layout of the home (stairs, tight rooms, hoarding, etc.) makes having a hospital bed, an overhead lift, a commode, etc. impossible.
Be aware that if the adult is still capable of making their own decisions, they must consent to a transfer to residential care. If you do not feel that your loved-one is capable of making this decision, ask for a geriatric psychiatry assessment before the discharge planning meeting.
Home Care Planning from Hospital
See more in the education blog on Understanding Home Care.
An unplanned admission to hospital is the way that adults will suddenly require home care – even if they were independent before the hospitalization.
Because of an extreme shortage of residential care beds and months or years-long wait list, the Ministry of Health has a ‘Home first’ mandate where care at home must be attempted before residential care will be considered (except in the most extreme cases where it can be proven that the home is unsuitable, or the adult would be unsafe). The attempt at home must ‘fail’ before residential care is considered.
If home care is required, a social worker or community liaison will put through the referral.
Be aware: it may be several days after discharge before a community case manager comes to assess the adult and then more time before care is put in place. The time in between discharge and care coming in needs to be filled by family, friends, or private home care.
Be aware: Public home care is too often unreliable as caregivers fail to show up or cancel at the last minute.
If the adult can’t manage at home and private home care is not a financially viable option – keep taking them back to hospital.
If the patient cannot return home and residential care is the next step, please read the next education article, Understanding Residential Care.
Further Reading
A notebook, used well, can save you significant time, stress, and missed information and appointments. It may even save your life. If something goes wrong, you will have all of the information you need to file a complaint. But, if everything goes right, it will give you the names for thank you cards and chocolates.
Miscommunication and Missed Communication
Miscommunication – but most often missed-communication – at all levels of the healthcare are so common that incidents are dismissed and just considered normal. Empowered patients and care partners are the plastic wrap between the layers of Swiss Cheese. What you see and say can make the difference between life and death.
This is, by far, the biggest, longest education alrticle I have ever written. It is a step-by-step guide on making a complaint that will result in change.As empowered patients and care partners we should make complaints when we have received inadequate, poor, or wrongful care in hospital or from our practitioners. This is a thorough guide on how to make effective complaints that will receive action.
Resources for Making a Complaint in BC
This is an extention of the last education article, How to Make a Complaint in BC. The Resources are listed in order of priority and sequence.
