Discharge planning: preparing for home care after hospital

And reviewing care needs after returning home

Being discharged from hospital isn’t the end of care. When an older person is leaving hospital, it’s important to consider how to support their recovery at home. Along with rehabilitation and ongoing nursing care, home care services can be arranged in advance, such as personal care, household chores, transport and more. The hospital is responsible for discharge planning to arrange services to meet the older person’s needs, but things can look different when they get back and adjust to the home environment.

While careful discharge planning can help older people and caregivers feel more confident and in control for the transition home, you can get support to review and adjust home care arrangements if new or different help is needed after an older person returns home after hospital.

The importance of discharge planning for caregivers

Knowing there is support in place can ease stress for an older person leaving hospital. Also, family members involved in care need to feel well equipped to handle things like medications, meals, mobility aids, transport, and other support for continuity of care.

What to expect before an older person leaves hospital
The hospital discharge planning team (doctors, nurses, and allied health staff) is responsible for establishing an older person’s needs and providing instructions to the caregiver for what to do after leaving hospital. A discharge planning meeting might be held shortly before discharge. The older person’s GP should be notified of any ongoing medical follow up and receive a copy of the hospital discharge summary.

Ask to receive information about:

• Recommended support at home, considering various types of home care services
• Referrals to a home care service or other support organisations
• Mobility aids and equipment needed at home
• Medications and how to administer them
• Contact information for help and any follow-up medical appointments

Patients of public hospitals may be eligible for a Post-Acute Care Program, which could include 2-4 weeks of community nursing, personal care, home care, and in-home respite. Unfortunately, there isn’t much consistency in the way people are linked in with these services, so it’s important that caregivers know to follow up and seek help.
This program isn’t available in the private hospital system at all.

Caregivers have a key role in supporting an older person’s smooth transition from hospital to home. Discharge planning will ensure as much as possible is put in place before a loved one returns home from hospital, as there’s a lot to do.

Home help after surgery or hospital stay

Caregivers can plan ahead for when an older person is returning home from hospital. There are many ways home care helps recovery from illness or injury. You might need to make some preparations in the home in advance.

Preparing the home for an older person’s return

• Clean and create space for mobility and extra equipment
• Consider temporary arrangements for the older person to sleep downstairs or in a more accessible room
• Home modifications might need to be installed – ramp, grab bars, handrails
• Hire or buy equipment such as shower chair, raised toilet seat, walker

Involve the family, and GP if needed. Gather information about the family’s availability and a list of care needs. Then develop a roster around when support is needed.

If you’re not available or not confident to assist a loved one with their personal care (eg: showering, toileting), you’ll need to arrange for some in-home care. We’ve addressed some of the main concerns an older person’s family might have, in our earlier post on in-home caregivers.

Adjusting back home from hospital

Encouraging an older person to accept the help they need can be tricky. It’s hard to know what help is needed until they leave hospital. As a caregiver, you’ve been so worried about their health, that planning for recovery wasn’t top of mind, and neither of you could visualise what it would be like.

When an older person gets home, away from the 24/7 hospital care, they might realise they need more help or different help to what was arranged.

While in hospital, doctors and nurses come to you at all hours, meals arrive to your bedside on a trolley, there are hospital staff to provide whatever assistance is needed. It’s a different situation at home, without around-the-clock care and suddenly it’s up to you to fix a meal and get to an appointment.

If you’ve realised after getting home that you need advice from a healthcare professional, we can help. We can meet with you and provide guidance to access the right home care supports. We will deal with my aged care for you to put home care arrangements in place that meet your loved one’s changing needs now and in the long term.

Reviewing your home care needs after a hospital stay

Early discharge planning is going to set you up to stay in control and be less stressed, knowing arrangements are all taken care of. And when things change after an older person returns home, you can get support to review your home care arrangements and adjust the services to meet an older person’s new needs.

Key considerations before and after a hospital stay

• Gather the information you need – from the GP, from the hospital team, from family members – so you have an idea of the older person’s likely needs and the resources available when your loved one returns home.
• Put as many plans in place as you can in advance. Set up the home, line up home care, understand the costs: who pays, what to pay, and when. Find out what’s covered by various programs.

If an older person needs more or different home care services after settling back in:

• Expert home care advocates like Empower Aged Care can deal with My Aged Care for you and coordinate the support you need. We’re experts at identifying the things that could be covered with government funding that you might not realise. We look beyond the immediate needs after returning home from hospital and consider long term care planning.

If you’re concerned about getting the right support for your loved one when they’ve returned home from hospital, contact Empower Aged Care. A Holistic Aged Care Assessment will put your mind at ease as we determine the right supports, liaise with My Aged Care, and arrange the services for you.

References
https://www.healthdirect.gov.au/hospital-discharge-planning
https://www.safetyandquality.gov.au/sites/default/files/2020-05/fact_sheet_-_discharge_planning-information_for_clinicians-_pdf-april_2020.pdf
https://www.betterhealth.vic.gov.au/health/serviceprofiles/post-acute-care-program