Hospitals/Rehabs and Discharge Planning

All it takes is a fall, a stroke, or a car accident and you or your loved one may end up in the hospital unexpectedly. This is when you need a patient advocate with experience working in the health care setting to help you answer the following questions:

  • Who is the most appropriate specialist?
  • Are the specialists talking to each other?
  • Are there important details that are slipping through the cracks?
  • Are your loved one’s goals of care serving as the foundation for treatment?
  • Is discharge from the hospital or rehab being planned too early?
  • Do you know how to care for your loved one after discharge back to home?

As your partner in care, we can help you understand the medical issues and the treatment options being presented. Perhaps you would benefit from a family meeting (even by video conferencing) so everyone can get on the same page. Maybe the hospital or rehab is pushing for a discharge that feels too soon, and you need help filing a Medicare appeal. If you are part of a marginalized group such as the LGBT community, we can help you find inclusive care, working to protect you from harassment and differential treatment.

Would you like help with discharge planning?
Give us a call at 302-200-9719.

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Hospital to home

We can visit you/your loved one at the hospital; discuss health status and progress with your hospital physicians, nurses, and therapists; interpret and relay labs, imaging, and vital signs for you; and even pick up your loved one at the hospital and bring them home.

If in-home caregivers are needed, we can find the best home care so your loved one has the support required for a solid recovery.

We can arrange for equipment and supplies, such as a hospital bed, a commode, a shower chair, a mechanical lift, or grab bars, that will prevent falls and ease the caregiving process.

New prescriptions will be filled and we can put them into pillboxes for you or arrange for automated pill dispensers to ensure the new regimen is quickly in place.

We can even make follow-up appointments with the appropriate specialists and transport your loved one to the visits, attend the visits, and report back to you about progress and any changes in the recommended treatment.

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Hospital to rehab

Perhaps the person you care for needs a few weeks in an inpatient acute-care rehab or skilled nursing facility to receive the medical supervision and therapies required to fully regain their health. We can help you pick the best rehab facility and make sure that discharge planning is incorporated into the facility’s initial comprehensive assessment. We can also attend care plan meetings to be sure your loved one’s requests and preferences are addressed.

When the time comes to move back home, we can help prepare the home environment. If long-term care is more appropriate, we can help you find the best assisted living or best memory care facility.

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Rehab to home

Once your relative has achieved enough functionality to go home, we do a home safety assessment to reduce fall hazards and other challenges. We set up any needed assistive devices and services that will support a continued recovery.

Perhaps home health visits are in order to continue physical therapy, speech therapy, occupational therapy, and/or nursing support.

We can support you with reconnecting with the primary care provider to get them up to date on all the changes and make any necessary adjustments to medication or the frequency of follow-up visits.

We can also support the family and/or paid caregiver(s) by providing education and training on the safest and most comfortable techniques with which to assist your loved one in their home.

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Discharge to long-term care

Sometimes a fall or hospitalization makes it clear that aging in place is no longer a safe option. Drawing upon our deep understanding of long-term care, we will talk with you, your family, and your loved one to determine which facility and location is the best, given personal values and family resources.

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It may be that your loved one needs to move out of town—even out of state—to be closer to family. We can assist with packing, arranging for transportation, and selection of appropriate long-term care.

We are part of a national network of care management professionals, so we can recommend a care manager in the new location to assist with local decisions, including adjustments to the new home environment if your loved one is going to move in with a family member.

Need help getting belongings packed up and shipped? No problem. We can help coordinate this part of the relocation process.

Need to put the original home on the market? Simple. We have a network of real estate professionals that we can refer you to with confidence.

A sudden hospitalization and/or change in your loved one’s condition is a shock for everyone. As your partner in care, we are there to walk beside you as you make difficult decisions and have to quickly arrange for new circumstances.

Give us a call at 302-200-9719.

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