Am I Ready to Go Home After a Hospital Stay?

One of the most challenging aspects of hospitalization for the elderly is preparing for the safest and most appropriate discharge plan. Oftentimes, elderly patients are discharged home following a hospital stay because they have not conveyed to the hospital staff that they do not have the support to be able to make a safe and smooth recovery at home. Worse, they may wait countless hours in an emergency room or hospital readmission. According to November 2022 report from Kaiser Health News, 2,273 hospitals across the country have been penalized by Centers for Medicare and Medicaid Services (CMS) for higher readmission rates.

There are many reasons why an elderly patient could be readmitted to the hospital. These include complications following a procedure, adverse drug reactions, premature discharge, inadequate post-discharge support, or communication in patient handoff. Some hospital readmissions are truly unavoidable; however, many of these patient setbacks could be avoided by evaluating the patient's home-based challenges and then determining the most appropriate level of care post-discharge.

The recovery process has just begun when someone is discharged from the hospital. Although the patient is deemed to no longer need hospital-level care, they will likely need some care (post-acute care in a facility or home) over the coming weeks and months. Many need intense skilled nursing or rehabilitation to return home safely. The appropriate type and intensity of care will be determined by several factors, including age, mobility, ability to perform activities of daily living (bathing, dressing, cooking, getting to doctor's appointments), and insurance.

Discharge Planning

CMS has published a discharge planning checklist for free on its website here. This is a valuable resource when you or a loved one is admitted to the hospital. The checklist summarizes all the questions you and your family member/caregiver should ask to prepare for a successful discharge.

Some critical questions include:

• What care do you qualify for? Home health? Skilled nursing? Inpatient rehabilitation?
• What equipment will you need to be safe at home?
• Are you ready and able to do everyday activities like bathing, using the bathroom, and cooking?
• If not, what support is available?
• If you have a caregiver at home, what skills will they need? For example, giving injections or changing a dressing?
• If you do not have someone at home, is it safe to be discharged home?
• What medications do you need to take?

About the Author: Kathy Stella, RN, BSN, CRRN, is the Assistant Vice President of Admissions and Case Management at Allied Services.

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