The Role of Discharge Planning
These entries will discuss in three parts the transition of an elder who normally lives at home, maybe with some assistance or in-home caregivers, but then is hospitalized and needs more extensive care after treatment. Let's say, mom was living at home but had knee surgery, or was hospitalized for treatment of pneumonia which left her weakened, or perhaps she had a fall and broke a bone. In today's world, hospitals tend to discharge these types of patients who clearly require further care pretty quickly. Hence the adage, "discharge begins at admission".
A hospital will assign a discharge planner to the case and assess what type of support the patient has in the home. The discharge planner has an obligation to determine whether a discharge to home would be safe for the patient. An elderly person with a significant injury (broken leg) or who had recent surgery would not likely be a candidate to return home if they live alone unless they can afford round the clock care giving to assist with toileting, grooming, transfer and repositioning and meal preparations.
Even if the patient lives with loved ones, their care needs might be too high to return home. For example, many patients leave the hospital requiring additional services that must be provided by professionals like physical and occupational therapies. Perhaps they need dressing changes for surgical or other types of wounds. Perhaps they need IV antibiotic therapy for infection. These are often referred to as 'skilled' services. Other times patients require less complex 'custodial services' which are more assistive type services with activities of daily living such as eating, bathing, dressing and grooming. This type of service is also called 'unskilled' service.
So to answer the question what 'level of care' would be appropriate requires an understanding whether the patient requires skilled versus unskilled services. If services are necessary that can only be provided by 'skilled' professionals such as licensed nurses, physical, occupational and speech therapists, then a stay in a skilled nursing facility (also known as a nursing home) is appropriate. Alternatively, if only episodic care is required by professionals, qualified in home nursing care might be appropriate if the patient has other support at home for dressing, bathing, grooming, toileting, etc.
Posted by: Denise A. Platt, RN, JD with Law Offices of Jody C. Moore, APC
