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Discharging Elderly Patients from Hospital To Home Or Residential Care

By: Paige Lennox

British Columbia has the second highest readmission rate after hospitalization of any province in Canada. Many of these readmissions are due to inadequate discharging elderly patients from the hospital.

If you or a loved one is in the hospital, you need to get involved and participate in discharging elderly patients from the hospital. CHAI Health Advocates are here to guide you in this process.

Five helpful tips for the patient/caregiver:

  1. Always have a second person present during discharge planning. Make sure the patient is never alone, coerced, or pressured into going home before arrangements have been made for adequate support and equipment.

  2. Ensure that both the patient and the support person have a copy of the discharge summary as well as any recent test/procedure summaries.

  3. Make sure that someone is with the patient during transport home and will remain at their home until they are stable.

  4. Notify the family doctor of the discharge as soon as possible to ensure continuity/consistency of care.

  5. If home care is put in place, make sure it is arranged before leaving the hospital.

Everyone needs to plan for their discharge from the hospital, no matter how minor the admission or procedure. The older the patient or more serious the illness or surger, the more important it is to pay attention to Discharge Planning.

For PLANNED minor to moderate procedures and surgeries, you should make sure you plan for the following:

  1. Transport: You will need to arrange for someone to pick you up once you are discharged from the hospital.

  2. Support: You will also need to arrange for someone to stay with you for 24-48 hours. This person can help with small tasks and watch for reactions to the anesthetic or pain medications. They should be prepared and able to call 911 if they notice the following symptoms:

  3. Unusual weakness, sleepiness, or not “bouncing back” as expected

  4. Excessive bleeding (if you’ve had surgery)

  5. Fever or signs of infection (excessive redness, skin hot to touch, pus draining at the surgical site). Disorientation or delusions are SERIOUS signs of infection for seniors.

For PLANNED major treatments and surgeries:

  1. Transport and Support: You will need to find someone who can pick you up and stay with you for a few days. They will need to watch for the same things as outlined above.

  2. Meals: If you don’t have someone to prepare meals for you, plan ahead and fill the fridge and freezer. You may want to set up a meal service and grocery delivery prior to hospitalization.

  3. Mobility: If you will need crutches or a walker, make sure you know how to use them and that your home is set up for their use.

  4. Personal care assistance: Your need for Home Health assistance is assessed in the hospital and cannot be pre-arranged. In BC, government assistance is subsidized (not free) and is based on your previous year’s income. The services provided are limited and are generally for only 20 minutes twice a day. Plan ahead, if you will need additional assistance.

For UNPLANNED hospitalizations or when your health situation becomes complicated:

  1. Paperwork: Do your paperwork ahead of time to ensure that your support person/emergency contact information is easily accessible. Complete a Representation Agreement (in BC) and other Substitute Decision-maker Designation forms, so you have someone to make decisions on your behalf if you are unable.

  2. Discharge Planning: Start talking about Discharge Planning early on in your hospital stay. Connect with social workers, transition liaisons, physiotherapists and occupational therapists to discuss what you are likely to need once you are home. It is never too early to start these conversations.

Discharge Planning

You should request a complete Discharge Planning meeting in the following situations:

  1. You do not feel your loved one should be discharged from the hospital.

  2. You foresee issues with safety and the need for equipment such as a bed and lift equipment.

  3. You foresee the need for home support and are unclear as to what will be provided by community services.

  4. You think transport home will be an issue.

Talk to the unit’s Patient Care Coordinator (PCC), Unit Manager, or Social Worker to arrange a meeting. Ask for a written plan, and take lots of notes. You should also make sure you have a support person with you during this meeting.

If you feel you are not being heard and are being pushed toward an unsafe discharge, immediately ask to speak to the following people, in this order:

  1. Health Advocate

  2. Unit Manager

  3. Patient Care Quality Office (PCQO) for the hospital (the contact information for this office is usually posted near most elevators).

  4. Director of Nursing

  5. Director of Medicine.

Most PCQOs will not get back to you for at least 48 hours and not at all on evenings or weekends. The more concerned you are, the more messages you should leave—don’t be shy about letting the office know if the situation is urgent.

Residential Care

If it is determined that transfer to a Residential Care facility is the only/best discharge option, a decision will have to be made about which Residential Care facility is appropriate.

Most provincial health guidelines operate under the First Available Appropriate Bed (FAB) policy unless you are willing and able to place your loved one in a private pay facility. Once your loved one is placed in a subsidized bed, you can request that they are put on a waitlist for a bed in the facility of your choosing (anywhere in the province).

Home/Residential Care is often, though not always, the best place to recover. Unplanned hospital discharges leave the patient and family unprepared and can often cause significant stress for everyone involved. The goal is to get home or into a long-term facility with adequate resources. Planning ahead reduces the risk of readmission and means a much safer journey to recovery.


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