Discharge Care Scenarios

While no two patient discharge cases are the same, there are many similar scenarios that rise in common and can lead you to have some concern about your patient's ongoing care and safety. Below are a few examples of potentially adverse discharge situations and some solutions to solving the problems.

Elderly man applying shaving cream

Gaining compliance of a plan of care

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Robert, 82, recently lost his wife of 60 years. "She's the one who took care of everything," he thought. He remembered how she paid the bills, took care of insurance and asked all the questions at the doctor's office. As her health failed, she even insisted on getting caregivers to ease the burden on him. "I want a husband," she said, "not a nurse." Even though she was now gone, she could still make him smile.

But right now, Robert was having a hard time with his own health care. He recently had surgery and wasn't sure if he was supposed to feel better than he did or not. There were so many instructions that he couldn't be sure if he was doing all he was or wasn't supposed to. And then there were so many doctors! Each time he had a visit, there seemed to be more instructions that just confused him even more.

Robert again thought about his wife's caregivers and wondered if there wasn't some similar type of help for him. So, he called the discharge coordinator who had assured him before he left the hospital that he could call if he needed anything. After he explained what his difficulties were, she referred him to a local in-home care service.

He had a nice call with a young lady who assured him that they could help get him to doctor's visits, sit with him while the doctor explained what needed to happen and then make sure that it all was coordinated with the plan of care he got when he left the hospital. She said his caregiver would help make sure his other doctors knew all the various aspects of his care. And if he needed, his caregiver would help him make lists so that he had clear instructions to follow for when she wasn't around.

"We want to help you get healthy and stay out of the hospital," she said. After hearing that, Robert started to worry less and looked forward to having someone to talk with again.

Middle-aged woman talking on a cordless phone

Preparing for environmental and medication safety

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Betty lives across the country from her elderly mother, who is about to be discharged from the hospital. Betty told Alison, the discharge nurse, that she remembered that during her last visit, she noticed a lot of clutter around the house including piles of magazines, knick-knacks on most surfaces and some hand-hooked rugs that were slippery on the hardwood floors. While the house was clean, Betty told Alison she was concerned that her mother's home was not safe for someone newly unsteady on her feet and likely hadn't been properly prepared for her return.

Betty also noticed that her mother's plan of care included a number of new medications. She knew her mother already had a number of prescriptions and began to worry that her mother might confuse the medications and not take some or all of them properly.

Alison told Betty that these were legitimate concerns and that her goal was to make sure Betty's mother was safe and took her medications properly. She recommended that Betty contact a transitional care services provider.

When Betty called, she learned that making safety improvements is among the first steps that these particular caregivers can make. They'll box up items for storage, remove loose rugs, and make sure pathways are clear for easy mobility. They'll arrange for grab bars and safety lighting to be installed, if needed. They could also refer contractors for Betty to talk to if more significant aging in place modifications were needed.

Betty was relieved when she learned that the caregivers would also help with medication management, including making sure all prescriptions are at one pharmacy and keeping an updated list with doses, times to be taken, special instructions such as "take with food" and when refills are due.

After arranging for caregiving services, Betty smiled and then set about making travel arrangements to come back and visit with her mom in a couple of months.

Smiling woman carrying a grocery bag

Nutrition management to improve outcomes

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Adam made a check-in call on a patient, Susan, who had recently been discharged. He learned from Susan's son that she had lost considerable weight since returning home from surgery and appeared weak. The son said the whole family was concerned and worried that their mother wasn't recovering like she should. Adam inquired about the family's ability to help, but learned while Susan's family lived locally, they each had active children and busy work lives so they were not able to be present on a day to day basis to make sure she had groceries, prepared meals or enjoyed company while she dined.

Adam referred Susan's son to a local in-home care service agency who he said could help provide nutrition and dietary management for his mother.

When Susan's son called, he told the agency that he and his family were able to provide for most of his mother's care, but that they needed help making sure she was eating properly when they weren't able to be there. The agency assured him that their professionally trained caregivers would review Susan's discharge paperwork and plan of care and contact her health care professionals to see if there were any specific dietary restrictions. They would work with Susan to create a shopping list, do the shopping, prepare the meals and make sure she was eating them. The caregiver would even join Susan at mealtime for conversation and companionship.

The caregiving coordinator pointed out that sometimes medications can make food taste funny so she would consult with Susan's pharmacist to see if there was something that could be done to minimize any of that discomfort.

Finally, the caregiving coordinator offered that, since Adam and his family were so busy, the caregiver could take Susan out for walks or to visits with her friends and church, once she was a feeling better, so she could continue to grow stronger both physically and emotionally.

Older gentleman seated with a cane

Finding help for the helpful one

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Joe is an independent type in his early 80s who has lived alone for years. His one adult child lives far away and has health issues of her own. His one adult child who lives far away has health issues of her own and many of his peers have passed on. Still active and able, Joe is usually the one who gives people rides and checks in to make sure his friends are doing ok.

But, this is an unusual time for Joe. He is about to be discharged from the hospital after hip replacement surgery. Sadly, he has no one available to help him through the discharge process. He is becoming a bit overwhelmed with trying to understand all of the information on the reams of paper involved in his follow-up care instructions. On top of that, he hasn't quite figured out yet how he's going to get home since he's the one who usually does the driving.

His transitional care nurse, Sarah noticed that Joe was feeling blue and snapped a bit at her when she came for a visit. After some probing and gentle cajoling, she was able to get Joe to talk about his concerns and needs and promised she would look into some resources that might be able to help during the transition period for his return home.

Sarah reviewed his insurance and learned that he had coverage for home care services. She called a local home care provider and spoke about Joe, the kind of man he is, and what his needs might be. The representative said she had the perfect caregiver candidate and arranged an interview with Sarah.

Sarah liked the gentle, but no-nonsense approach that the caregiver displayed and introduced her to Joe. Sarah explained to Joe how his insurance company would pay for the extra help while he recuperated. She talked about how the caregiver was trained and qualified to walk Joe through his discharge process and instructions. She noted how the caregiver could help him develop simple lists for managing his medications and diet needs until he felt better and was able to manage on his own. Sarah even added, "I like you a lot Joe, but I don't want to see you back here and this caregiver can really help you while you recuperate so that you can get well and avoid having to be readmitted."

Sarah told Joe that the caregiver could drive him home, get him settled and make sure he had his favorite foods from the local farmer's market. And if he was too tired, the caregiver could whip up a few meals for him too.

After the conversation, Sarah noticed Joe's brow was a bit more relaxed and the smile she was used to seeing had returned. She left to let Joe and his new caregiver get to know each other better while she started the paperwork to get Joe back home.