Hospital Discharge and Needed Help at Home

Sometimes it's really hard to see when help is needed at home for mom.  Patients have a hard time admitting they need assistance because they are used to doing everything independently.   As the children or significant other, we tend to side with them not knowing the level of assistance they are going to require at the time of discharge.  The best thing we can do is to allow the homecare agency with trained medical professionals to enter the home and complete their assessment to determine what assistance is needed at this point.  So, mom is now being discharged from the hospital with a referral for a home care agency.  Mom of course is saying “I don’t need help!”  The social worker at the hospital disagrees.  The family agrees to allow the agency to come to the home and complete an assessment of the current needs.  At this point,  you are not aware of what issues there are or if they are significant.  The home care agency has two main objectives.  The first is to allow the patient to return to their home, and the second is to evaluate their safety in the home and their ability to remain safe.

The assessment contains different parts to see where the needs are for a particular patient.  The cognitive part is simply to see if the patient can understand the plan of care, and follow on a daily basis to maintain safety.  Can mom understand the discharge medication schedule and tell you when they are to be taken and what the pill is for?  Does she have a good understanding of time of day in regard to meals and appropriate nutrition and hydration?  Is she able to get food and prepare it properly while maintaining safety?  Is she safely using her new equipment (example walker) to perform her activities of daily living like toileting, washing up and even brushing her teeth?

The agency will also evaluate the home for safety.  Are there throw rugs that need to be removed?  Does the patient have all the equipment needed for recovery? Perhaps a shower chair for showering?

Once the cognitive status is evaluated,  it makes it easier for the agency to create their plan of care for the patient.  If there is a cognitive impairment,  it may be more difficult for the patient to agree to homecare.  The nurse is usually accepted well, and also used as a bridge for allowing a home health aide to enter the home.  The agency will start out slow with a few days a week to build relationships with the patient.  After a few visits, the hours may be increased as recommended in the plan of care.

If there is no cognitive decline,  it is much easier for the agency to assess the needs and create the plan of care.  The patient will be aware that they need assistance on a temporary basis until recovery takes place.  The trained staff that the agency places in the home will constantly evaluate for safety and understanding.  At the point of recovery the agency will make the necessary recommendations for continuing some kind of care.  The main objective with the homecare agencies is to supervise and assist the patient for a safe environment in the home and to prevent re-hospitalization.

Referrals for home care are not always generated with a hospital discharge.  Individuals that need supervision or assistance in their home can hire a homecare agency.  At times, the assistance can be minimal to assist with activities of daily living and prepare meals for a few hours a day, while others   may require a caregiver to live with them if they have greater needs.  Just ask for recommendations and place a phone call to the agency of your choice to discuss your personal needs.  Homecare agencies can put your mind at ease that your loved one is safe at home.