I've recently been helping a friend who has been managing her mother’s transitions from a hospital to a rehab facility, and then again to another rehab facility that wants to send her home before she, or her family, is ready. It reminded me of how tough family caregiving transitions can be. As a longtime family caregiver of many including both parents and my sister, I’ve been through many of them — some smooth, others unexpected and rocky. Caregivers play a crucial role in easing transitions, helping to ensure that loved ones adjust and get appropriate care along the way.
Moving our loved ones from one care setting to another is stressful for everyone involved. It’s invariably complicated and confusing, and I’ve often experienced poor communication among hospitals, facilities and family caregivers. Family caregivers play a key role in preventing hospital readmissions. We are the one consistent part of our loved ones’ care teams. Yet, all too often, family caregivers feel left out of the transition process. That’s why it’s up to us to be proactive.
Care Transition Checklist
• Contact discharge planner/social worker
• Discuss options/plans with patient
• Talk with health care practitioners and therapists
• Arrange for next step in care:
- Facility: Visit; review care provided, residents, visitors, meals, cleanliness, certifications, ratings, complaints, costs and insurance coverage
- Home: Understand insurance coverage of home-based care; arrange for home modifications, medical equipment, personal care, medical care, therapies, meals, transportation, visitors/socialization, prescriptions
• Get printed medication list, prescriptions and discharge instructions
• Get hands-on demonstrations/instruction on medical/nursing tasks; photos/videos
• Get appropriate clothing and personal supplies
• Arrange for transportation upon discharge
• Ensure transfer of medical records between facilities/providers prior to, at time of and following the transition
When faced with a care transition, planning is key, even if you have only a few days. Here are some ways you can help your loved ones with care transitions:
1. Do your homework ahead of time.
It’s a good idea to be aware of the hospitals and rehabilitation, skilled nursing and assisted living facilities in your parent or other loved one’s immediate area. Talk with your parents about their preferences, goals and wishes about where, if needed, they would want to be treated, recover and live. Review the ratings of Medicare-certified facilities at the Medicare Compare site, and talk with family members of people who have been there. A little bit of basic research ahead of time will lower your stress levels in a crisis when you may need to make decisions quickly.
2. Start planning for discharge at the beginning of a stay at a hospital or rehabilitation facility.
Don’t wait until discharge is imminent. Ask to speak with a hospital discharge planner or social worker for help planning your loved one's next steps, care, transportation to their next place, insurance coverage and payment plans.