If you have assisted a family member through a course of subacute rehabilitation (up to 100 days under Medicare Part A following a hospitalization), you are no doubt familiar with the process of the “family meeting.” This is a meeting at the facility attended by the members of the patient’s treatment team — the head of nursing, dietary, recreation, physical therapy, occupational therapy, speech therapy, and even the physician — where the patient and their family advocate discuss the goals that are in place for the patient, the progress being made, and the patient’s ongoing “skilled needs.” These meetings take place every few weeks during the skilled care/rehabilitation process.
Then there comes the day that the patient is advised that s/he will be discharged. Decisions have to be made quickly — is the patient staying in the facility for long term care? Is the patient going back to the community? If the patient is returning to the community, there may be a myriad of issues to address. Sometimes patients have multiple needs — the house may be inaccessible; they may need a companion in the home; they may be unable to prepare their own meals; they may have ongoing clinical problems that need specialized nursing attention; they may have behavioral disorders related to dementia which require special handling. Each patient has unique needs, and they may not be as capable as they were before this latest medical crisis.
When you are coordinating the discharge, the facility’s treatment team can be an invaluable source of information and suggestions. Since home health aides for the basic activities of daily living (ADL’s) often must be hired privately — as generally the cost cannot be billed to Medicare — family caregivers may be inclined to set up an informal casual volunteer arrangement rather than bring in many hours of professional hired help. However, the team at the facility may have an objective viewpoint on what is actually needed for a safe and successful return home, and this can be very useful to the family.
What are the questions to ask? Not just “can he come home?” Patients can usually go home if the proper supports are in place. You need to go well beyond the equipment that may be needed. Instead, try these concrete questions: 1.What do your aides have to do for him every day, starting when he wakes up? 2. Does he need physical assistance with showering, or just a shower stool to sit on and someone standing by? 3. Do you recommend that he have someone next to him while he is walking around? 4. Can he move his wheelchair around by himself? 5. Are there any special dietary issues we need to know about? 6. Does he get out of bed at night and try to walk around, or does he sleep through the night? 7. Do you think he needs to have an aide in the house throughout the night? 8. Does he ask for assistance, or just wait until someone comes in and asks him a question? 9. Does he eat his meal without someone assisting or prompting? 10. Do you have any thoughts on whether he can safely be left alone in the house?
Careful planning can prevent a crisis. Take advantage of the skills and knowledge of the rehab team to help you prepare for a good transition home.
Contact us for legal advice and advocacy on a wide array of elder care issues, including participation in family meetings … (732) 382-6070 http://www.finkrosner.com/contact.html