Patients and their families concerned about caring for a patient when discharged from a hospital or other facility should use discharge planning checklists to help discuss post discharge needs and coordinate post discharge care plans and arrangements with health care providers, insurers and the patient’s personal and care network to help ensure continuity of care after discharge.
Patients and families often are put at an unnecessary disadvantage in their efforts to care for a patient after discharge from a hospital, skilled nursing or rehabilitation facility or other inpatient care setting because the timing of discharge decisions often comes much sooner than expected and patients and their families are ill prepared to meet the post-discharge care needs of the patient when these decisions come because they lack sufficient information and experience to understand what resources and other needs the patient will have post-discharge and how to access and coordinate the arrangements to fulfill these needs.
To position the patient and their families to be better prepared to respond, patients and their families should start planning for discharge as soon as possible. Patients and their family and friends serving as caregivers should include discharge preparedness and planning in discussions for planned procedures requiring hospital or other admissions and as part of the admissions process in the case of unplanned admissions, and continue to include discharge preparation and planning discussions among the matters regularly discussed throughout the patient’s inpatient stay.
As part of discharge planning discussions, questions that patients and their caregivers generally will want to ask health care providers and payers about generally will include best case, worst case and most typical case expectations about:
- The patient’s prognosis, recovery process and timing, and functionality landmarks and needs expected along the way;
- What criteria are used to determine when the patient is ready for discharge;
- What post-discharge health care needs and functional limitations on the patient’s activities of daily living to expect after discharge and what resources or other arrangements need to be coordinated to fulfill those needs;
- When the health care provider predicts the discharge of the patient from the facility most likely will occur and what events could expedite or delay that date;
- Information about post-discharge care and support orders and resources;
- Post discharge complications or events to watch for and how to respond; and
- Any other information relevant or necessary to support and care optimally for the patient after his discharge.
Discharge planning checklists obtained from health care providers, health plans case management resources, and even credible sources on the internet often provide invaluable tools to patients and their family’s efforts to anticipate and prepare to meet the post-discharge planning needs of patients. Patients and their families can access these resources from a variety of sources. One good place to start often is the inpatient facility itself. Patients and their families should consider asking their health care providers to share any checklists or other criteria that the health care provider uses or recommends to determine discharge readiness and preparations. Other checklists or resources often also can be accessed from the case management or other resources accessible through the patient’s health plan. A wide range of free and other discharge planning checklists and other tools also generally are readily available from a wide range of credible sources on the internet such as the Your Discharge Planning Checklist published by the Centers for Medicare & Medicaid Services to assist patients and caregivers in planning and preparing for a patient’s discharge from a hospital, nursing home or other care setting. See also Compass Health 6 Step Checklist For Hospital Discharge. While patients and their families often may still experience financial or other practical challenges in completing the necessary arrangements even when using these checklists and other resources, obtaining as much information as possible with as much lead time as possible generally will help minimize these challenges by helping patients and families anticipate and prepare those arrangements that can be met more easily and to begin the discussions and other explorations needed to find solutions to meet the other needs of the patient that may require more coordination or exploration to address or discuss other alternatives with providers, payers and others about these needs and their resulting concerns.
PROJECT COPE: COALITION ON PATIENT EMPOWERMENT 