At Choices in Senior Care, we have assisted numerous families involved with transitioning a loved one back home following a nursing home stay. Most of these cases have involved folks who have had life altering health changes. How do you make the transition from nursing home or other rehab back into your home setting?
The first thing that we do as Geriatric Care Managers is an assessment of the individuals life changes. How has this event changed the way you will perform your activities of daily living? How has it changed the way that you will use your home? What support systems will you need to live with the changes that this event has brought into your life? What will these changes cost you financially? We find that most of the families who call us are pretty lost about where to begin, and ask us to help them envision what this new picture will look like once they are back in the home setting.
We feel that it is really important to get input from every professional who is caring for your loved one. As Geriatric Care Managers, we spend time in the nursing home speaking with the social worker, nurses, physical, occupational, and speech therapists, dietician, and the aides that care for the client on a daily basis. We find out what they can or can't do; what the expected progression will be over the next few weeks, what the client is eating, whether or not the client is sleeping at night (sometimes we have to work on switching day/ night modes after an illness), safety concerns, and how the client is coping with the changes. We also assess the financial and legal situation to make sure that finances are in place to care for the client long term, and to make sure simple things like Power of Attorneys and Advanced Directives are intact for the family.
Once we've completed the time in the facility, we travel to the client's home. There, we will go through each room with a family member and consider how the home might need to be changed to accommodate the client. What equipment needs to be purchased or rented? If a hospital bed is needed, where will it go? Are the paths wide enough for a wheelchair or walker? Is the bathroom usable in it's current condition? Are there issues with entering the home? We also assess what family members are available to help, and when? Do we need a caregiver schedule if multiple adult children will be caring for the client?
Once we get a really good picture of what the client and family will be dealing with, we start the discharge coordination. Ideally, there should be a discharge planning meeting between the family, client (if appropriate), Geriatric Care Manager, and professionals from the facility. The family can ask questions, and the plan is discussed in detail of what support will be arranged for the first few days at home. Typically, Medicare will pay for at least a couple of weeks of home health and therapy to ease the transition. As geriatric care managers, we make sure that all equipment is ordered, any non-medical home care is in place and ready to go, and the family knows what their schedules will be the first few days home. We also typically communicate with the physician, and home health companies to make sure that everyone is on the same page. Transportation is usually arranged by the nursing home social worker.
On the day of discharge, we usually arrive at the home a few minutes before the client. We make sure that the client is settled, he has all of his medications, his non-medical home care has arrived and knows what to do, and the family is comfortable with everything. There will be many changes to which the client and family must adjust. We make sure all the equipment is working as it should be working. If we've done a good job, there will be few surprises that day.