The Weakest Link in Our Healthcare System in America

The Weakest Link in Our Healthcare System in America

So, you’ve navigated your frail parent’s hospital stay and now it’s time to go home. You probably can’t wait to leave but … what’s coming next is extremely uncertain. Leaving a hospital with a frail older adult in tow is like stepping off a cliff blindfolded.

The hospital discharge process is arguably the weakest part of our entire healthcare system. I know this sounds backwards, but the less time your parent is in the hospital, the more Medicare money the hospital gets to keep. Your mom’s safe transition home is not the hospital discharge planner’s priority. It’s her job to get you out as quickly as possible.

Here are five concrete things you can do that will fill this gap so that leaving the hospital will not feel like such a free fall.

Get a Good Plan BEFORE You Leave

The very first thing is to have the hospital to make you a “discharge care plan” that clearly lays out what you need to do, how to do it and when.

For example, say your mom fractured her hip and will now need physical therapy. How much physical therapy will she need, for how long and from whom? All of these questions need to be answered by professionals before she leaves the hospital.

Of course this seems like good common sense but hospitals vary in how much attention they pay to this. So, you may need to force them to give you a good plan — and more importantly — TO MAKE SURE YOU UNDERSTAND IT. Just because a nurse says, “this is easy” (as she quickly instructs you in administering an injection (!)) doesn’t mean it is.

This checklist is a good guide. Print this out and sit down with the discharge planner, and/or the doctor on staff to help with these things. Be pesky. As my friend says, “Ask, ask, and ask again.”

Be Pro-Active on Rehabilitative Care

Now, there’s a decent chance that the hospital or your doc will tell you that your parent needs to go to another facility for “rehabilitative” care. There are two main types of places where that usually occurs: a special rehabilitation hospital or a skilled nursing facility (i.e., nursing home). Of those two, the vast majority of patients, getting rehab care in a facility, get it in a nursing home.

But DON’T worry. This does not mean that’s where your parent will end up permanently. Most rehab patients go into the skilled facility for an average of about 25 days and then go home. Medicare covers full cost for the first 20 days and then there’s a copayment.

These places are Not Created Equal. Go to Medicare’s Nursing Home Compare and look for the “four or five-star” facilities. Generally speaking, one and two-star facilities should be avoided.

Prepare to Get Help at Home or Look to an Assisted Living for a Short Term Stay

You’re certainly going to need some help when you get home. Managing a frail elderly parent at home directly after a hospitalization is really challenging. Please try and arrange for some help in the home at least for a short period of time.

Medicare will pay for some home health care in certain circumstances and you can find a Medicare home health agency on Medicare’s Home Health Compare.

While home health is an option, that works only if the needs are scheduled.  With some many variables and unknowns coming out of a hospital stay, looking toward an assisted living community with 24/7 nursing care and meals, programs and rehab programs – a short term stay of 30 days or more is a great option for your loved one.  .

Be the Medication CZAR

Keeping yourself and everyone else straight about your mom’s medications will be a moving target. You’ll need to track medications carefully.
Also, when you get home, ask the pharmacist to guide you through the medication transition, to make sure you know how to help your parents follow the directions and take everything as it’s prescribed and to discard old prescriptions.

Make a Doctor’s Appointment

Sounds simple but it’s so, so important. The research shows that going for a follow-up doctor’s appointment prevents landing back in the hospital. So, make the appointment!

It’s also important that you’re ready to engage in a meaningful way with that doctor. She’s really relying on you to report on your mom’s situation. One of the geriatric care managers I talked to a few weeks ago told me that she types up a one page list of all her observations and concerns, in addition to the medication list, and brings it all in with her.

Arrive at the doctor’s office with this and the medication form and you will be in better shape than most people.

Lastly, Don’t be Hard on Yourself

I really want to give you a little perspective here…. this whole hospital to post-hospital process can be difficult for you and your mom AND ALSO for every other frail elderly hospital patient in the entire country. Seriously. The federal government, as I write this, is spending tens of millions of dollars trying to straighten it out and make it better.

So do not feel bad that you can’t make this smooth sailing. This is one of the roughest patches of water you’ll encounter in your entire caregiver journey. Call us today to help you navigate this process to a successful outcome.

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