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Home / Elder Law and Geriatric Care / Hospital Discharge: Making the Transition to Home or a Skilled Nursing Facility

Hospital Discharge: Making the Transition to Home or a Skilled Nursing Facility

Elder Law and Geriatric Care, Medi-Cal/Medi-Cal/Medicare, Elder Care, Geriatric Care

by:  Guest Blogger Renee Seligman, Patient Advocate

When caring for a senior who is going to be discharged from the hospital, it is important to address the following:

  1. Medication Reconciliation: Often the attending physician at the hospital will make changes to a patient’s medication list. It is important to reconcile the list prior to discharge with the hospital’s Discharge Coordinator or Nurse Case Manager to ensure accuracy. All prescriptions that need filling must be sent to the patient’s pharmacy prior to discharge. Always check with the pharmacy to ensure the prescription orders were sent and are being filled. If the patient is being transferred to a Skilled Nursing Facility, confirm with the facility that all prescriptions will be filled in a timely manner so the patient does not miss a scheduled dose as Skilled Nursing Facilities use their own pharmacy.
  2. Patient’s Medical History: Being aware of a patient’s current and past medical history is vital when communicating with health care providers. If this information is not readily available, it may be obtained from the patient’s Primary Care Physician. The hospital will also provide a Discharge Summary that includes a medication list, lab tests, imaging results, medical history, diagnosis and follow-up recommendations. This summary must be read for accuracy so that any necessary changes may be made to the Summary prior to discharge.
  3. Durable Medical Equipment: It is important to make sure any and all durable medical equipment that is part of the patient’s Plan of Care, such as an oxygen condenser or a C-PAP machine, are available and in good working condition. If transferring to a Skilled Nursing Facility, it is imperative that a patient who requires oxygen has it available to him or her the moment they arrive.
  4. After Care: If the patient is going home, the level of required after care must be determined. How independent is the patient? Does the patient require part-time or 24 hour care? Who will provide the care? How will the care be paid for and for how long? Is the patient able to accurately manage all of his or her medications in a safe and timely manner? Should the patient have an extra level of personal security, such as an alert button worn as a necklace or bracelet that can be used to reach 911 in case of an emergency?
  5. Home Health Agencies: Most insurance plans will cover services provided by a Home Health Agency after discharge from the hospital or Skilled Nursing Facility. These agencies provide a Nurses Assessment, Physical and Occupational Therapy and a Home Health Aid. This is a temporary service requiring a referral from a physician. The hours of service per week vary and are usually less than 10 hours per week. This service does not replace skilled nursing or assisted living services in the home.
  6. Medicare Discharge Review: If a patient or family member feels a discharge is happening too soon, the Beneficiary and Family Centered Care Quality Improvement Organization in your area will conduct a review to determine if it is medically necessary for a patient to remain in the hospital. For More information go to MEDICARE.GOV.
  7. Follow-up Appointments: It is important to make an appointment with the patient’s Primary Care Physician as soon as possible after discharge from a Hospital or Skilled Nursing Facility. The Primary Care will want to be updated as to the patient’s health condition. Additionally, he or she will want to review and possibly make changes to the patient’s medications.

Caring for a senior loved one after hospital discharge can be emotional and challenging. Being prepared and having a thoughtful plan in place may ease some of the stress for family members and caregivers.

Guest Blogger Renee Seligman works as a Patient Advocate managing medical care for individuals with complex healthcare needs. Many of her clients are senior citizens. Renee has a Bachelor’s degree in Public Speaking and a minor in Health from San Jose State University.  She can be contacted at (831) 278-2380 or via email at patientadvocate100@gmail.com.

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