Helping Your Loved Ones Transition with Care and Confidence 

Supporting a family member’s journey from a hospital to a rehabilitation facility, and eventually back home, can be a challenging and emotionally taxing experience. This guide aims to shed light on the complexities of managing these transitions and offers insights into how family caregivers can play a vital role in ensuring their loved ones receive the best care possible. Drawing from personal experiences as a dedicated caregiver, we’ll explore the importance of effective communication, advocacy, and proactive involvement in the transition process. 

Understanding the Challenges: Transitioning a loved one from one care setting to another is a multifaceted task that often involves medical, logistical, and emotional hurdles. Many caregivers encounter issues such as inadequate communication between healthcare providers, facilities, and family members, leaving everyone feeling overwhelmed and confused. Recognizing these challenges is the first step toward managing them effectively.

The Crucial Role of Family Caregivers: Family caregivers are the consistent and unwavering advocates for their loved ones throughout the transition journey. As a primary caregiver, possess valuable insights into our loved ones’ needs, preferences, and medical histories. This knowledge makes us indispensable members of their care teams, capable of preventing unnecessary hospital readmissions and ensuring continuity of care.

Conclusion: Managing the transition from hospital to rehab to home is an ongoing process that demands patience, resilience, and dedication. Family caregivers are the unsung heroes of this journey, and your unwavering commitment plays a pivotal role in ensuring the best possible care for your loved one.

Tips for a Smoother Transition:

• Medication Management: Keep a detailed record of your loved one’s medications, including dosages and schedules. Ensure that all healthcare providers are aware of these medications, and watch for any potential drug interactions or side effects.
• Healthcare Documentation: Maintain a comprehensive file containing medical records, test results, and contact information for healthcare providers. This will facilitate smoother communication and continuity of care.
• Family Support: Involve other family members in the caregiving process. Distributing responsibilities can alleviate the burden on one person and provide emotional support for both you and your loved one.
• Community Resources: Explore available community resources, such as support groups, respite care, and home healthcare services. These resources can provide valuable assistance during the transition and ongoing care.
• Advocacy with Confidence: Don’t hesitate to speak up if you feel that your loved one’s needs are not being met. Trust your instincts and advocate for the care that you believe is necessary for their well-being.
• Self-Care: Caring for a loved one during transitions and beyond can be physically and emotionally draining. Prioritize self-care by seeking respite, taking breaks, and maintaining your own health.
• Review and Adapt: Continuously evaluate the care plan and make adjustments as needed. Your loved one’s condition and requirements may change, so staying adaptable is essential.

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.

Get help.

If you’re unable to manage all aspects of the transition due to being at a distance or other responsibilities, consider enlisting the help of a geriatric care manager or aging life care expert, or a case manager associated with their insurance.

Determine location and costs. 

The goal is for your loved ones to be as independent as possible for as long as possible, so consider their quality of life, goals, current abilities (mobility, cognitive functioning) activities of daily living (ADLs) and instrumental activities of daily living (IADLs, like driving), rehabilitation, safety and care needs. What is the best place for them right now? Observe them in physical therapy sessions; talk with doctors, therapists and those who have been helping with personal care. Determine insurance coverage and out-of-pocket costs. Make the best decision you can with the information and resources you currently have.

• Transition to a rehabilitation facility, skilled nursing, assisted living facility or group home: Ask which facilities would be best for your loved ones’ specific needs in terms of on-site services provided, staff-to-patient ratio, type and frequency of rehabilitation services (acute, subacute, skilled nursing, etc.), transportation provided, activities and meals. Consider current visitation rules, location and ease for family and friends to visit. Evaluate the steps the facility is taking to protect residents from COVID-19. If possible, make an unscheduled visit to the facility and get a feel for cleanliness, residents’ happiness and staff attitudes. Request that the discharge planner facilitate the transition.

• Transition to their home or a family member’s home: Prepare the home and arrange for in-home services. Ask the physical and occupational therapy departments or a certified aging-in-place specialist to help you evaluate the home for safety. Review the AARP Home Fit Guide to help you determine if home modifications are needed, such as installing ramps, handrails, lighting, grab bars, etc. Obtain medical equipment (such as a wheelchair, walker, cane, oxygen, shower chair, raised toilet seat) and determine insurance coverage. Try to have these things in place prior to discharge. The discharge planner can help you find home-based medical services and understand insurance coverage for services like primary care, laboratory services, X-rays and therapies (such as physical, occupational or speech therapy). Your loved ones may initially be eligible to receive short-term home health aides and other services covered by Medicare, but you’ll need a plan for future care. Contact the local area agency on aging to ask about caregiver support and affordable home- and community-based services and ask for an in-home assessment.

3. Advocate for them … and for yourself. 

In any transition, you’ll be advocating for your loved ones, ensuring they are informed as appropriate, that plans are in their best interests, and that they receive the best care along the way.

Check admission status. If your loved one is in the hospital using Medicare, find out if they are under “observation status” and how that could affect Medicare coverage if they are discharged to a rehabilitation facility.

Understand discharge timing. If you believe your loved one is being discharged too soon, whether they aren’t ready or you haven’t had enough time to set up their next location, don’t be intimidated. You can file an appeal. Talk with the insurance company and the hospital or facility social worker or hospital admissions office about the appeals process.

Monitor care and communication. Ensure that medical records and information about your loved ones’ conditions, treatments, medications and care needs are being shared between the hospital, facilities and care providers. Never assume communication or transfer of medical records has taken place. Confirm adherence to discharge plans and instructions.

Be there. Research indicates that patients do better with follow-up if a family caregiver is there to hear and note discharge instructions for medications and care. So, make it your business to be there — either in person or virtually, via video chat or phone — for each transition. If you are unable to do so, make sure to arrange for a care manager, family member or friend to be present.

Insist on the three “I’s”: information, inclusion and instruction.

• Information: Obtain printed copies of all pertinent information, including the loved ones’ current medications list and prescriptions (flag any changes), and a summary of their visit (diagnosis, treatment, prognosis, surgeries, limitations, etc.), rehabilitation recommendations and discharge orders. Note any scheduled follow-up appointments. Share this information with those who will care for your loved ones next (doctors, facilities, home health aides, professional caregivers, etc.).

• Inclusion: Proactively make certain that you are included in care planning discussions and are informed of changes and decisions. If you have health care power of attorney for your loved ones, you can make decisions for them.

• Instruction: Nearly half of family caregivers are expected to perform follow-up medical and nursing tasks, so be sure to ask for detailed instructions/training (which is required by law in some states). When my dad was discharged from the hospital with a feeding tube, I was given just a few minutes of explanation on how to deal with it. It was complicated, and we were back in the hospital multiple times when it clogged. I received help from the home health nurses, but you can bet the next time we had a hospitalization I advocated more strongly for the information I needed to do my job as a caregiver.

4. Get realistic about the future. 

Sometimes hospitals or rehab/nursing facilities are unrealistic about what setting is best for our loved ones, or how much a family can handle in terms of future care. It’s up to you to stay rooted in reality. I’ve learned to ask a lot of questions, observe loved ones in therapy sessions, monitor their medications and assess their capabilities, and weigh it all along with their needs, wishes and quality of life. I assess the home situation and potential facilities realistically. If you can’t provide all the direct care yourself, you are not a failure. You are still doing your job as a caregiver when you coordinate the care. As I often say, I’ve learned that I can do anything, but I cannot do everything! Line up the support you’ll need from care managers, care providers, family members and friends. Build your team.

RESOURCES

• AARP’s Caregiving site includes information about nursing homes, care at home and medical and nursing task how-to videos. The community resource finder includes a directory of care providers, housing options and other supports. The Long-Term Care Cost Calculator can help estimate care costs. 
• My book Juggling Life, Work, and Caregiving has a chapter on crisis management, including hospitalizations and discharge planning, and information on caring for loved ones in a facility or at home.
• Next Step in Care is United Hospital Fund’s program that has a number of guides for family caregivers dealing with hospital stays and discharge planning, rehabilitation and home care, including their Rehab to Home Discharge Guide.
• Medicare’s discharge planning checklist includes key Medicare and Medicaid phone numbers, as well as information about how to appeal if you believe your loved ones are being discharged from a facility too soon. 

Conclusion: Managing the transition from hospital to rehab to home is an ongoing process that demands patience, resilience, and dedication. Family caregivers are the unsung heroes of this journey, and your unwavering commitment plays a pivotal role in ensuring the best possible care for your loved one.

Remember that you are not alone; there are support systems and resources available to assist you in this challenging role. Seek out the guidance of healthcare professionals, support groups, and fellow caregivers who can provide valuable insights and emotional support.