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Navigating the Maze - 3 Hospital Discharge Planning Tips for Family Caregivers

Mar 21, 2023


Imagine this:

Your elderly dad fell while shaving.

An ambulance takes him to the nearest hospital’s emergency department. There, they decide to admit him for observation overnight - or longer.

It’s never a good time for these things to happen. You’re afraid because you don’t know how serious things might be. 



Emergencies can happen at any time

“Will I have to take more time off work,” you wonder. “Will I need to change dressings, deal with pumps and intravenous fluids, or give injections? How will I know what new medicines Dad will be taking? What do I do with the old ones? Can I afford to throw away the ones I just bought and pay for new ones? What’s going on?”

You might experience guilt: “Why did he fall in the first place? I was afraid this would happen. I should have done more, but what?” And then you might feel guilt for a different reason: "I hate that Dad had to go to the hospital. But at least he is in a safe place; I can get some rest and sleep. He gets up to the bathroom multiple times a night, and I can’t remember the last time I had a good night’s sleep." 

 Discharge planning - preparing for when your dad will go home - is the furthest thing from your mind. 


What is discharge planning? 


Hospital discharge planning is a series of activities where hospital professionals prepare your loved one to leave the hospital. It is designed to equip you and your loved one to leave the hospital safely and with the resources to continue healing and recovery. It is a coordinated effort for your doctors and staff; and for your loved one and you, too.

The goal is peace of mind. With a well-thought-out plan, you can minimize the risk of returning to the hospital for a problem that could have been avoided.

The discharge plan takes into account whether your loved one is leaving the hospital and going home, or is transitioning to short-term skilled care (sometimes called rehab), or to long-term care in an assisted living, memory care or nursing care facility.

The plan may include instructions on managing medications, appointments, therapy and providing medical supplies and equipment. Importantly, it should include the information and skills training you, the family caregiver, require in order to succeed when the care shifts from the hospital to your home and your responsibility.

The goal of discharge planning is to ensure that your loved one receives the appropriate care and support they need after leaving the hospital. The aim is to prevent hospital readmission, and to promote your loved one's overall health and well-being. 



The 3 Hospital Discharge Planning Tips for Family Caregivers 



Tip #1. Start discharge planning right away.

Tip #2. Monitor the likelihood: when your loved one goes home, will it be more likely to the old normal, or instead to a new normal?  

Tip #3. The discharge is not the end but is just a beginning. 

1. Start discharge planning right away. 



Start with your loved one's records

As soon as you know your loved one will be admitted to the hospital, you should begin planning for the time your loved one will be going home.  

I recommend that you begin even before your loved one has an emergency. What do I mean?

Create a system for organizing your loved one’s records. This system is an orderly way to keep up with the records and paperwork for handling your caregiving responsibilities. An obvious benefit: you are prepared for doctor visits and insurance issues.

But have you thought about how a records system equips you to track progress, make decisions and plan for care after the hospital stay? Consider these additional benefits: 


Benefit #1: You can inform the doctor

You have necessary information to help the doctor begin a plan of investigation and treatment. What medicines is your loved one taking, and is this the most current list? Does your loved one have allergies? What vaccines has she received? Does he drink, smoke? 

You get the idea.

Having this essential information at your fingertips expedites the diagnostic and treatment process, and may even reduce the number of unnecessary tests and procedures, with their medical risks and costs in dollars and pain. 


Benefit #2: You can advocate for your loved one

Your system is your tool for staying on top of hospital events and decisions. It helps you keep pertinent records, and to journal your understanding of your loved one’s condition and its progress, what it means, and what you need to do. This comes in handy when making decisions and having to explain those decisions to others - and to yourself! 

It prepares you to provide accurate and up-to-date information to the healthcare team. This can help them make more informed decisions as you collaborate about your loved one’s care. 

If you have a clear understanding of your loved one’s treatment and progress, you can speak up when you feel that their needs are not being met. Your records support your arguments, and your loved one receives the best possible care.


What you will need

You can put a paper-based system together quite easily. If you choose electronic devices, then look for those with the same features as the paper-based variety. These features include.  

1. Daily Care Journal

2. Medication Log 

3. Symptom Tracker 

4. Medical Appointment Log 

5. Care Plan Template

6. Emergency Information Sheet 

7. Calendar 

8. Contact List

9. Progress and Milestone Tracker 

10. File Folder or Binder

I have provided a fact sheet describing these features in more detail here. 


2. When your loved one does go home, will it be to the old normal or to a new normal?

There’s a lot to think about and learn when your loved one goes to the hospital. You must communicate with multiple professionals, from the primary doctor to the nurses, to specialists and to technicians. Sometimes it seems too much to absorb. So many questions, so much information. What do you really need to understand about your loved one’s condition?

I recommend that you make it easy for yourself. You don’t need a medical degree. After all, it’s not your responsibility to fix your loved one. Your biggest concern is “Will things be different? If so, how?”

To put it simply, your purpose for asking questions of the doctors and other professionals is to gain enough information so you have a working knowledge of what just happened, what does it mean in terms of your loved one’s quality of life, comfort and functioning when they leave the hospital, and will you need to make new changes in your roles as your loved one's caregiver.

Will your loved one continue functioning like they did prior to this hospital stay? That would be returning to the old normal, or maybe better. That’s what we all hope for.

On the other hand, will they need new medicines, treatments and therapies, and resources? That might mean more work for you and new adjustments for both your loved one and for you. You might even require new information and new skills. Are you prepared for that? That’s a new normal.

Therefore, during your loved one’s hospital stay, you want the doctors and professionals to give you information that tells you:

“What’s happening?” - What is my loved one’s condition right now? How serious is it? Is there anything we could have done to prevent it, or to prevent it from happening again? 

“What does it mean?” What is the doctor's best guess that your loved one will get better? What is their best guess that things could get worse? What factors are leading them to their conclusions? 

“What should I do?” Ask the professionals what they think your loved one will need when they go home. What do they think you will need? Who can you talk to now to help you get ready for then?



3. The discharge is just the beginning. 




When the time comes for your loved one to go home, you may think, “We can go home now. That part is over”. But it’s really just beginning a new phase. Yes, your loved one’s in-hospital treatment is over, and has come to an end. Now, however, the recovery and healing must continue in the home setting, under your responsibility.

You’re probably thinking about this already, and it’s making you nervous. If you, however, have been seeking and receiving information that answers your questions, “What’s happening, what does it mean, and what do I do?” you are far ahead in the game. You have clarity about what to expect, and are more prepared than perhaps 90 percent of family caregivers at discharge time.

Just as importantly, your doctors are prepared. While they have provided you with vital information and skills that you need, you have been an invaluable resource for them as well. Your knowledge and understanding of your loved one makes them more effective.

Your loved one’s doctors really want them to do well when they go home. And these professionals want you, the caregiver, to succeed as well.

Your success and your loved one’s good outcomes lets them enjoy the pride of a job well done. But they are also held accountable if a poorly executed discharge plan requires your loved one to return to the hospital from an avoidable complication or event.

The hectic workflow that hospitalists face is truly unfortunate. The daily pace frustrates them as much as it frustrates you. Take my word for it, I know. Having worked as a hospitalist based in the hospital and as a primary care physician based in the office, I’ve seen both sides.

But the situation is what it is, and you have to work with the cards you’ve been dealt. That is one reason why I started this work of supporting family caregivers and their doctors.

If you, the caregiver, are well informed and prepared to advocate for your loved one, you help your doctors succeed as well. And everyone from the doctors to the nurses and discharge planners will thank you. I believe that, even though I realize that too often, we doctors don’t give you family caregivers credit for the job you do.




To get the most out of hospital discharge planning, follow these 3 tips:

1. Start discharge planning right away.

2. Keep track of whether things are more likely to return to normal, or be a new normal.

3. The discharge is not the end but is just a beginning.

Remember, you, the family caregiver, are the leader of your loved one’s care team. The better informed and prepared you are, the better you can support and advocate for your loved one. As a result, your loved one gets better care, and you get the information, skills and support you need.

This approach helps everyone involved. Unfortunately, there are times when the hospital stay does not turn out as hoped. Your loved one’s disease sometimes exceeds the capabilities of the medical team’s efforts. Your loved one gets worse despite their treatments. Your loved one may not be fortunate enough to return home. Perhaps they don’t even survive the hospital stay.

Even in then, these 3 tips can prepare you to face such a difficult outcome. You will have the assurance that though the result was not what you hoped for, you still did your job with diligence and compassion, and your loved one knew they were being well cared for because you were there.  



Rather than anxiety and helplessness, even guilt or anger, you feel relief, satisfaction and a sense of accomplishment. And you have given your doctors and other hospital professionals the gift of satisfaction and accomplishment as well.


With these three tips in mind, how prepared are you? Are you prepared to get what you need when your loved one goes in the hospital, and especially when it’s time for them to leave?

Let me know in the comments, especially if you have an answer I didn’t mention.


If you are a caregiver for a family member, friend, or neighbor, please consider taking my Caregiver Quiz


Until next time.

Forrest Jones MD

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