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What to Expect When You’re Discharged from the Hospital

With new healthcare rules and changes we need to understand what is involved in discharge planning.   Discharge planning helps to make sure that you leave the hospital safely and smoothly and get the right care after that. This sounds simple, but it can be frustrating.
You might wonder why you are leaving. You might have questions about what will happen when you get home and what your family can do to help. You may worry about who’s going to pay for your care.
You, the person who is caring for you, and the planner work together to address your concerns in a discharge plan. Whether you go home, to a relative’s home, to a rehabilitation facility, or to another health care setting, your plan outlines the care you need.  Let’s review the “risk” involved and the qualifiers:
Low Risk Discharge

  • Independent in activities of daily living
  • Caregivers in the home and available to assist
  • Live alone with community support
  • Independent with management of chronic disease
  • Adherent to treatment plan
  • Consistently followed by practitioner

Moderate Risk Discharge

  • Lives alone with limited community support
  • Requires assistance with medications
  • Issues of health literacy
  • History of mental illness
  • Polypharmacy (taking more than 7 medications)

If you are deemed to have two or more of these qualifiers you may be referred to home care or skilled nursing for observation and assessment, teaching and training, performance of skilled treatment or procedure, physical, speech or occupational therapy, medical social work, or telehealth care management.
High Risk Discharge

  • Lives alone with no community support
  • Lives with family that is not actively involved in care
  • Clinically complex—e.g., multiple co-morbidities, repeat hospitalizations or Emergency Room visits, needs considerable assistance to manage or is unable to manage medical needs
  • History of falls
  • Acute/chronic wound or pressure ulcer
  • Incontinent
  • Cognitive impairment
  • History of mental illness
  • COPD/ Diabetes/ HIV/AIDS
  • End stage condition
  • Requires assistance in transferring, ambulating, medication management or management of oxygen and/or nebulizer

This patient is high risk for rehospitalization and should be referred to home care services ASAP.
Get involved with your discharge planning. You (or your caregiver) can give the discharge planner important information about your daily activities. Tell your discharge planner what you and your caregiver can and can’t do, and make your wishes known. As always, call the JFS NNORC if you need help with accessing services. We can be reached at 514-2023.
 

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