Post-Hospital Care (Team)
Part 2: The Post-Hospital Discharge Planning Team
The goal of this guide is to prepare you for the discharge process. We will walk you through a hospital discharge—important considerations, the key players involved, and steps to take after discharge. This guide is useful for patients of all ages. However, if you need help during the discharge process, contact our expert team at 650 462-1001 to help you coordinate post-hospital care for your loved one.
Click here to organize post-hospital care for your loved one.
Here is an overview of the hospital discharge process. If you would like to jump to a particular section, click the corresponding heading.
Planning for Discharge
The Discharge Planning Team
Recovery Facilities vs. Home
Support Your Loved One’s Recovery
The Discharge Planning Team
Now that you know the basics of a thorough discharge plan, we’ll explore some of the key players involved in the discharge process. If you would like to learn more about one of these professionals, click the corresponding heading to jump to that section.
The Patient
The Physician
Nursing Staff
Discharge Planners
Case Managers
Care Managers
Social Workers
Skilled Therapists
Private Duty Nurses
Caregivers
Family
The Patient. The patient is the most important member of the discharge planning team. Their needs and preferences guide the actions of all other members. The patient or their representative should communicate what the patient is most comfortable with and open up the discussion on any desires and concerns. From there, the discharge team will share their thoughts and recommendations, and work with the patient on fulfilling these goals.
The Physician. The physician is responsible for evaluating and signing off on the final discharge plan. A well-thought-out plan is safe for the patient: it anticipates and addresses risks, and it appropriately meets the patient’s medical needs. The physician is also responsible for prescribing medications. The physician’s primary focus is the physical and mental wellbeing of the patient. While the physician may not have control over the care provided at the receiving facility or by the in-home agency, they do have the ability to make a well-placed decision on whether or not the facility/agency’s standard of care is appropriate for the patient’s post-discharge needs.
Nursing Staff. Nurses hold some of the responsibility for ensuring the patient is ready for discharge. Fortunately, they have a great understanding of their patients. Nurses have cared for your loved one since the moment they entered the hospital. Based on their experience, they are aware of each individual’s status, ability, and willingness to follow directions. Because of their knowledge, nurses can provide valuable feedback to the family and care team.
Discharge Planners. Hospitals usually have discharge planners on their staff. Often, a discharge planner is a nurse, social worker, or hospital administrator. They have a good awareness of local resources and maintain healthy relationships with rehabilitation hospitals, nursing facilities, hospice organizations, and home health companies. They can provide clarity on different care options and whether or not they are covered by insurance or private pay. Discharge planners are responsible for ensuring that a patient is released from the hospital to the environment that will provide the most appropriate care.
Case Managers. Discharge is a complex process. It involves multiple people who are all concerned about a person’s care arrangements. Case managers focus on care coordination, financial management, and resource utilization to yield cost-effective, patient-centered solutions. They decide what the patient needs during a single episode of care.
Case managers can play an especially important role in discharge planning for patients with more complex needs associated with an acute hospital stay. They can help ensure that discharge goes according to schedule, so that the patient is able to get out of the hospital as soon as they are safely able to do so. Case managers are often a patient’s biggest advocate in the discharge planning process.
Care Managers. Care managers come from a variety of backgrounds and work one-on-one with people with disabilities or chronic illnesses, usually in their home or permanent residence. They develop a care plan under the direction of the patient. The difference between case management and care management is their focus: case managers focus on a single episode of care, while care managers focus on a patient’s overall quality of life.
While there are geriatric care managers that specialize in working with the senior population, most care managers work with patients of all ages.
Skilled Therapists. Depending on the individual needs of the patient, skilled therapists may be able to assist the discharge planner by providing an assessment of the patient’s abilities and/or weaknesses. Skilled therapists include:
- Occupational Therapists (OT) – OTs help patients develop, recover, or maintain skills needed for everyday activities. They assess the patient’s abilities and consider whether or not they will be able to safely and independently function in their new or former environment. Occupational therapists commonly help older adults experiencing physical and cognitive changes, children with disabilities, and individuals recovering from injury.
- Physical Therapists (PT) – Physical therapists evaluate the patient’s abilities and recommend an appropriate next level of care that ensures their safety. They can help patients reduce pain, promote mobility, restore function, and manage their condition.
- Speech Therapists (ST) – Patients who have survived a stroke or other neurological condition may experience communication problems. Speech therapists assess a patient’s language abilities and recommend therapies that will improve their ability to communicate.
Skilled therapy is offered by private practices, rehabilitation facilities, skilled nursing facilities, and some home health agencies. It is usually covered by Medicare, up to a certain limit.
Private Duty Nurses. If your loved one is prepared to transition home, they may need skilled care to support their recovery. Home health may be restrictive when it comes to what it covers. Private duty nursing can be more flexible.
Nurses can provide such services as:
- Wound care management and surgical site monitoring to prevent infections
- Intravenous (IV) therapies
- Airway/management care
- Medication management and administration
- Vital signs monitoring to ensure recovery is going as it should be
- Teaching visits for clients and/or their family members
- Palliative care to enhance the overall comfort of the client
- Other skilled services
Private duty nursing is an ideal solution for individuals who may not want to transition to a skilled nursing facility, but are not ready to transition home by themselves. Private duty nurses can provide the professional support they need, allowing them to enjoy the comfort of healing at home.
Caregivers. There are a variety of care professionals to consider when transitioning from hospital to home. A professional caregiver can assist with activities of daily living, which include bathing, meal preparation, and other daily needs. Caregivers cannot provide medical care or administer medication. Hire the care professional that can safely assist your loved one with their needs. Together, a nurse and caregiver can provide your loved one with the medical care and daily assistance that they need to enjoy a smooth recovery.
Family. No one knows your loved one as well as you do. Perhaps you already provide care for your loved one, or you are willing to lend a hand with their recovery. Either way, let the discharge planners and care team know what you are capable of helping out with and what you can commit to. A family’s ability, availability, and willingness to provide care is important for the future well-being of the patient.
From there, you can plan supplemental care around your own schedule and abilities. If you are not comfortable fulfilling all of the responsibilities for your loved one’s care, a nurse or caregiver can come on an ongoing or as-needed basis to assist with your loved one’s recovery plan. For example, a private duty nurse can lead a teaching visit and show you how to administer intravenous medication.
Caregivers or nurses can also provide respite care, which is temporary care in order to provide relief for the patient’s usual caregivers. It’s easy to get burned out. An extra hand can help with the responsibility of caring for a loved one.
All of these health care professionals have specialized knowledge to help your loved one smoothly transition out of the hospital. Together, the discharge planning team can ensure a safe recovery for your loved one.
Learn about discharging to Recovery Facilities vs. Home in part 3 of this guide. Or, download the full guide here!
To learn more about how a private duty nurse can ease the transition into post-hospital care, call (650) 462-1001 to speak with a NurseRegistry Care Advisor.
