This post is for Social Workers working in facilities.
Seniors who are discharged from hospital have been found to have a very high rate of re-admission through the Emergency department .
This is a heartbreaking finding; seniors may present for re-admission with further physical injury, additional care needs rendered through emerg adds costs to the ‘system’, and last but not least, these re-admissions can be very discouraging to you as the health care professional point person. It’s a no-win situation for everyone.
5 things that you can do to keep things from going off the rails at home for your senior patients
1. Discharge letter – Make sure that your patient receives a copy of their discharge letter before they leave hospital. Provide a copy to whomever is there to accompany the person home. This improves the chances that follow up appointments get made, that medication changes are followed and that the patient and their family are completely ‘in the loop’ regarding recent medical history.
2. Follow up appointments – Try to book the initial appointment for any procedures or specialists before the person leaves hospital. Need blood work 3 days after discharge? Book an appointment for your patient with a visiting lab service. Chances are the blood work will actually get done as ordered.
There can be a lot of organization required for a frail senior to simply to get to a lab for bloodwork; assistance to get out of bed, to get dressed, to prepare a meal, to manage the stairs at the front of their house, to take a walker, to arrange for transportation, negotiating the entranceway, elevator and hallways of the lab, waiting, leaving the lab, arranging return transportation, negotiating the stairs back into their house (not to mention the need for a drink and a bathroom break). A visiting lab service can be a good alternative. There is a charge for visiting services but it may be worth it for the convenience.
3. Medications – If there’s one thing that may actually prevent a fall or readmission on its own, is making sure your patient has their medications up to date and organized. If your patient has a family member who can organize their meds in a dossette, or has private care where a Registered Nurse can load their dossette each week, great. If not, ask your patient if they’d be okay with you faxing their medication list to their pharmacy so that it can be bubble packed.
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4. Medical alert system – If your client lives alone, ask if you can provide them with a referral for a medical alert system. Many of companies will waive the set-up fee if the referral comes from a health care professional. This may be just the incentive your patient needs to accept this service. (If they are agreeable, contact the service before the patient leaves hospital and arrange an appointment for the day after discharge.)
5. Food– It’s so basic that it’s easy to overlook. Try and find out if a family member has been to the patient’s home recently to check on the food situation. Do they have food in the fridge and in the cupboards? Is it edible (you’d be amazed at what we find – and don’t find – in people’s kitchens). Proper nourishment and hydration are key to getting patients back on track after a hospital visit or set-back.
Do these 5 things during hospital discharge and improve the chances for your frail elderly patients to go home….. and stay home safely.
About Eldercare Home Health
We’ve been working with Social Workers and Discharge Planners, and caring for seniors throughout Toronto, since 1995.
We are the only elder care service in Toronto that provides PSW care that is actively case managed by Registered Nurses – at no additional charge. If you have an elderly patient who needs additional care in hospital, at home or with their Hospital discharge, contact us today.
- No-charge assessment by Registered Nurse
- All initial assessments are conducted by a Registered Nurse, not a marketing person or “care coordinator”
- We have a Registered Nurse on call 24/7 for emergencies so there is always someone knowledgeable to talk with
- All PSW caregivers are directed and supervised by Registered Nurses – at no additional charge