Rich OBoyle, Publisher
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Individuals who are discharged from hospitals (after surgery) and rehabilitation
facilities (after a stroke or hip replacements) are increasingly in need of in-home care.
Family caregivers should be aware that they may have to continue some of the medical and
personal care regimens at home that had been performed by professionals in the facilities.
Discharge planning begins early during the hospitalization and rehabilitation processes.
It involves the patient, family, and rehabilitation staff. The purpose of discharge
planning is to help the patient continue their improvement outside of a clinical setting
and in a more homelike environment.
Some of the things discharge planning can include are to:
- Make sure that the patient has a safe place to live after discharge.
- Decide what care, assistance, or special equipment will be needed.
- Arrange for more healthcare services in the home (such as visits by a home health aide).
- Choose the health care provider who will monitor the person's health and medical needs.
- Determine the caregivers who will work as a partner with the patient to provide daily
care and assistance at home, and teach them the skills they will need.
Preparing a Living Place
Many stroke survivors, heart patients, or hip replacement patients can return to their own
homes after a hospital stay or rehabilitation. Others need to live in a place with
professional staff such as a nursing home or assisted living facility. An assisted living
facility can provide residential living with a full range of services and staff. The
choice usually depends on the person's needs for care and whether caregivers are available
in the home. The patient needs a living place that supports continuing recovery.
It is important to choose a living place that is safe. If the person needs a new place to
live, a social worker can help find the best place. Not all hospitals provide discharge
planning assistance, so it is essential to be proactive: research available resources and
press the hospital for assistance.
During discharge planning, program staff will ask about the home and may also visit it.
They may suggest changes to make it safer. These might include changing rooms around so
that the patient can stay on one floor, moving scatter rugs or small pieces of furniture
that could cause falls, and putting grab bars and seats in tubs and showers.
It is a good idea for the patient to go home for a trial visit before discharge. This will
help identify problems that need to be discussed or corrected before the patient returns
Deciding About Special Equipment
Even after rehabilitation and surgery, some patients continue to have trouble walking,
balancing, or performing certain activities of daily living. Special equipment can
sometimes help. Here are some examples:
Cane: Many people who have had strokes use a cane when walking. For people with balancing
problems, special canes with three or four "feet" are available.
Walker: A walker provides more support than a cane. Several designs are available for
people who can only use one hand and for different problems with walking or balance.
Ankle-foot orthotic devices (braces): Braces help a person to walk by keeping the ankle
and foot in the correct position and providing support for the knee.
Wheelchair: Some people will need a wheelchair. Wheelchairs come in many different
designs. They can be customized to fit the user's needs and abilities. Find out which
features are most important for the stroke survivor.
Aids for bathing, dressing and eating: Some of these are safety devices such as grab bars
and nonskid tub and floor mats. Others make it easier to do things with one hand. Examples
are velcro fasteners on clothes and placemats that won't slide on the table.
Communication aids: These range from small computers to homemade communication boards. The
stroke survivor, family, and rehabilitation program staff should decide together what
special equipment is needed. Program staff can help in making the best choices. Medicare
or health insurance will often help pay for the equipment.
Caregivers who help loved ones who have survived a stroke or extensive surgery are usually
family members such as a husband or wife or an adult son or daughter. They may also be
friends or even professional home health aides. Usually, one person is the main caregiver,
while others help from time to time. An important part of discharge planning is to make
sure that caregivers understand the safety, physical, and emotional needs of the stroke
survivor, and that they will be available to provide needed care.
Since every medical condition and recovery is different, people have different needs for
help from caregivers. Here are some of the things caregivers may do:
- Keep notes on discharge plans and instructions and ask about anything that is not clear.
- Help to make sure that the patient takes all prescribed medicines and follows
suggestions from program staff about diet, exercise, rest, and other health practices.
- Encourage and help the person to practice skills learned in rehabilitation.
- Help the person solve problems and discover new ways to do things.
- Help the person with activities performed before their surgery or hospitalization. These
could include using tools, buttoning a shirt, household tasks, and leisure or social
- Help with personal care, if the person cannot manage alone.
- Help with communication, if the person has speech problems. Include the stroke survivor
in conversations even when the person cannot actively participate.
- Arrange for needed community services.
- Stand up for the rights of the patient.
If you expect to be a caregiver, think carefully about this role ahead of time. Are you
prepared to work with the patient on stroke recovery? Talk it over with other people who
will share the caregiving job with you. What are the stroke survivor's needs? Who can best
help meet each of them? Who will be the main caregiver? Does caregiving need to be
scheduled around the caregivers' jobs or other activities? There is time during discharge
planning to talk with program staff about caregiving and to develop a workable plan.
Adjusting to the Change
Going home to the old home or a new one is a big adjustment. For the former patient, it
may be hard to transfer the skills learned during rehabilitation to a new location. Also,
more problems caused by the stroke may appear as the person tries to go back to old
activities. During this time, the stroke survivor and family learn how the stroke will
affect daily life and can make the necessary adjustments.
These adjustments are a physical and emotional challenge for the main caregiver as well as
the stroke survivor. The caregiver has many new responsibilities and may not have time for
some favorite activities. The caregiver needs support, understanding, and some time to
rest. Caregiving that falls too heavily on one person can be very stressful. Even when
family members and friends are nearby and willing to help, conflicts over caregiving can
- Comprehensive Home Safety Checklist
- Choosing In-Home Care Assistance
- Medicare and Home Health Care
- Moving Your Elder In With You: Practical Tips and
- Preventing Falls
- The Caregiver's Guide to Home Modification
- Finding Local Transportation Services
- Selecting an Adult Day Care Center
- Extensive Stress Management articles and
resources in the I, Caregiver Channel
Care Without Medicare by Joseph Jackson
Your Limits When Caring for Aging Parents by Vivian Greenberg
- The Complete Eldercare Planner by Joy Loverde
- Caregiver's Handbook: A Complete Guide
to Home Health Care by the Visiting Nurses Association of America
Nursing Homes: Getting Good Care There by Sarah Greene Burger, et al.
Merck Manual of Medical Information: Home Edition (1999) by Robert Berkow (ed.)
- Additional resources, including excerpts,
reviews, and interviews are available in the ElderCare