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Senior Services Program Care Transitions

Last Updated 5/19/2010 9:27:38 AM


Senior services  care transitionsWhen you or a family member is ready to be discharged from the hospital, this may involve a transition to home, a rehabilitation facility or some other setting. Remember that discharge does not necessarily mean the patient has fully recovered, but rather that the physician has determined that his/her condition is stable and does not need hospital-level care. Sometimes patients and their families have unrealistic expectations about what they can do on their own. It is important to be realistic about what type of support is necessary, both for the patient and the caregiver.

Your care coordinator will assist you and your family member or caregiver with this next step. If possible, meet with the care coordinator early in the hospital stay to discuss your probable needs and what support is available. If you or the patient is going home, the care coordinator will provide you with information about homecare agencies and necessary medical equipment. If you need assistance managing at home, the care coordinator may also make a referral for you to see a case manager from the Community Services Agency of Mountain View who will visit you at home. If discharge is to a rehabilitation or convalescent facility, you will receive a list of possible facilities. Time permitting, family members can visit these facilities while the patient is still in the hospital.

The care coordinator is there to assist with the immediate transition from the hospital to the next level of care. If you need information or assistance with longer term planning or have questions about community services or resources, discuss your concerns with an eldercare consultant, located in the Health Library and Resource Center.

When you or your family member gets ready to leave the hospital, there are some important things to keep in mind in order to insure a safe transition and to avoid readmission to the hospital:

  • Make sure that you have a copy of the discharge instructions and that you understand them. Ask questions.
  • Have a list of all your medications, their dosages and instructions and make sure that you understand how and when you are to take them.
  • Report any new medications, along with the medications that you were taking prior to your hospitalization, to your primary care physician. Your doctor may need to make some changes to your original medications or to their dosages.
  • Have instructions for your follow-up appointment(s) with your primary care physician and other doctors. Be sure to keep these appointments.

You or the patient will receive a telephone call within one week of discharge from Family/Eldercare Services to see how your recovery is progressing and whether you have any additional needs or questions. If you need assistance with in-home or other services, you may call our eldercare consultants at any time.

Resources:

Medicare Discharge Guide

Universal Medication Record, El Camino Hospital, Available in English and Spanish

Speak Up: Planning Your Follow-up Care, by The Joint Commission. Available in English and Spanish