Care in Hospital and Discharge Planning
Being admitted to a 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 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 informing your health team of 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.
Understanding 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 the 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 thing 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 a hospital, finding out who to talk to about the patient’s condition and plan of care takes a massive amount of time. I often hang around the nurses’ station to catch the right person than in my client’s room.
If you are the care partner/substitute decision maker/Representative, it’s essential to know that you can call the nursing unit!
Find out as soon as possible who the key healthcare professionals are in 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 have the 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 hospital admission 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 not good news. Assume that discharge will happen sooner than expected before the patient or loved ones are ready.
Be aware that doctors have little influence over when discharge will occur. Once the patient is ‘medically stable,’ discharge can occur.
It is essential to find out who is responsible for discharge planning. Find out who will decide on the planned discharge date (bed control, a unit manager, social worker, occupational therapist, etc.) 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 to send the patient home with home support before considering a transfer to assisted living or long-term care. Residential care will only be considered if the patient ‘fails’ to manage at home.
Financial Considerations
If you need long-term support at home, public home care has serious limitations, and hiring private home care is significantly more expensive.
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 considerable concern for surviving spouses who may have many more years to live. Discussions should occur long before a crisis, and your Enduring Power of Attorney should be 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? The Occupational Therapist is often the best person to discuss your home situation. The Social Worker is often the best resource if additional care or long-term care needs 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 cannot be avoided? If so, could they be retrofitted with a stair lift? (Grants are 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?
Most areas have a profound lack of respite and long-term care beds. You must prove the need and explain 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 assemble the meeting. Still, 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 affordable.
The home's physical layout (stairs, tight rooms, hoarding, etc.) makes having a hospital bed, an overhead lift, a commode, etc., impossible.
Be aware that if the adult can still make their own decisions, they must consent to a transfer to residential care. If you do not feel that your loved one can make 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 hospital admission is a 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 a months—or years-long waitlist, the Ministry of Health has a ‘Home first’ mandate. Under this mandate, care at home must be attempted before residential care is 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.
A social worker or community liaison will put through the referral if home care is required.
Be aware that it may be several days after discharge before a community case manager comes to assess the adult and more time before care is implemented. Between discharge and care arrival, family, friends, or private home care must fill the time.
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 the 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. You will have all the information required to file a complaint if something goes wrong. 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 healthcare is so common that incidents are dismissed and 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 the most significant and longest education article I have ever written. It is a step-by-step guide to 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 the hospital or from our practitioners. This is a thorough guide to creating effective complaints that will receive action.
Resources for Making a Complaint in BC
This is an extension of the last education article, How to Make a Complaint in BC. The Resources are listed in order of priority and sequence.
