The source to consult for a care plan will depend on whether an individual is moving from hospital to home or a residential facility, or directly seeking care at home due to changing needs.
Through a Hospital Discharge Planner
The period following a discharge from a hospital can be filled with uncertainty and even danger, with confusion over care resulting in new or worsening symptoms. This can be eased, however, by securing a comprehensive discharge plan clearly indicating needs and care — before leaving the hospital.
Lay the groundwork for this plan well before the likely release date by contacting the hospital’s discharge planner. This person, usually a nurse or social worker, should coordinate the discharge and recommend any additional local resources.
The discharge plan should specify:
- Future care, including medical treatments, medical transportation, and homemaker services
- When nursing, therapeutic, or custodial care services will begin, along with contact information for the providers
- Medications and instructions on using them, as well as information about special diets and treatments
- Follow-up medical appointments
The discharge planner should address additional concerns, including:
- Services the patient will be eligible to receive after discharge, whether they can be arranged in advance, and whether financial help or coverage will be available
- Whether physicians or other medical specialists will be added — and whether the patient and others involved in the care can meet with them before the end of the hospital stay
- Instructions for refilling or obtaining medications or medical supplies after discharge
Do not leave the hospital until you feel secure about the plan of care — and do not sign the discharge plan unless you understand it completely. If the discharge planner does not provide all the necessary information, contact the hospital’s patient representative or ombudsman for help.
Through a Home Care Provider
People who have not recently been hospitalized, but who need outside caregivers to stay safely at home, can contact a home care provider directly — and as a first step, should secure a detailed written plan of care to address their needs.
Find out whether nurses and therapists are required to evaluate the patient’s individual needs — and how the agency handles this. Be sure those involved consult with the patient’s doctor, who is supposed to approve the original care plan and all changes to it. Family members may also be able to make important observations or suggestions to help make the plan of care work better for the individual.
Also be sure that the treatment is documented, with a written schedule of tasks to be carried out by each caregiver. And ensure that the patient and family members get copies of this plan along with solid explanations of all planned treatment.
In coordinating care, the agency caregivers should report perceived needs for changes in treatment to all doctors involved in the care. While this sounds like an obvious step, it is often overlooked in practice. It may be best to insist on documented evidence of this regular communication.