Issues to Consider
When a family member moves from one care setting to another—say, from the hospital to home or a rehab facility, or rehab to home, you need to be vigilant. It is a time when many people wind up back in the hospital because of poor communication, shoddy coordination or medical errors.
Hospitals can be vague in their discharge instructions about the care required at home, directions might be complicated, or a patient may be confused about medications or not know that a medication can have severe side effects.
Speak with a transition coach.
Some hospitals have transition coaches or care transition coordinators who help patients move between different care settings, keep professionals and families in the loop and advocate for the patient. There are also community-based organizations that may partner with hospitals. Ask your hospital, rehab or long-term care setting what they offer.
What to ask.
Here are some questions that you should have clarified before your parent moves from the hospital or rehab to home:
- What is Mom supposed to do if she has side effects from medicine or her condition worsens?
- What symptoms does she need to watch for?
- When should she seek medical help? For instance, what happens if there’s a problem after her doctor’s office hours? What constitutes the need for a visit to an urgent care center or the emergency room?
- When should she have a follow-up appointment with her primary care physician? Schedule it! Ask the office if she is eligible for a home care nurse or physical therapist who will come to the house. (Also, ask the discharge manager at the hospital or rehab what benefits you qualify for.) You might what to consider hiring a professional care coordinator.
Dad’s regular doctor may not even know he has been in the hospital or rehab, or about new medications prescribed.
Write down everything in a notebook, online and/or in a Personal Health Record booklet that can help you organize information. This includes updated medication dosages and pills, how Mom is feeling and any questions either of you may have for the doctor. Your parent needs to share their Personal Health Record at all medical visits and with the pharmacist.