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    • Going Home and Staying Home: Good Planning Makes Transitions Safer and Easier
      January 17, 2013

      Being discharged home from a skilled nursing facility is exciting, but it can also be scary. What if you forget to take all of your medications? How will you keep track of doctors’ appointments? Are you ready to resume all of your daily activities? What if your family has trouble coping with your illness? Does your caregiver have all of the information he or she needs to help you?

      Discharge planners and social workers at the nursing home will help you get ready to leave the skilled nursing facility. And Medicare has created a discharge planning checklist that can help you know what you need to ask before you leave the nursing home. Medicare encourages patients to use the checklist as soon as they arrive at the nursing home, so that preparation begins early.

      Some of the items on the checklist include:

      • Ask about problems to watch for and what to do about them. Write down a name and phone number to call if you have problems.
      • Write down your prescription drugs, over-the-counter drugs, vitamins and herbal supplements. Review the list with the staff. Tell the staff what drugs, vitamins, or supplements you took before you were admitted. Ask if you should still take these after you leave.
      • Ask if you are ready to do the activities listed below. Circle the ones you need help with and tell the staff.
        • Bathing, dressing, using the bathroom, climbing stairs
        • Cooking, food shopping, house cleaning, paying bills
        • Getting to doctors’ appointments, picking up prescription drugs
      • Ask for written discharge instructions that you can read and understand, and a summary of your current health status. Bring this information and your drug list with you to your follow-up appointments. (Centers for Medicare and Medicaid Services)

      The checklist also includes information for the caregiver and is broken into sections including “Your Condition” and “Recovery and Support.”

      Kindred Nursing knows how important smooth discharge and continued good care and recovery are for our patients. In Massachusetts, consented patients will be taking part in a pilot program aimed at reducing avoidable readmissions to acute care hospitals. Facilities in Kindred’s Massachusetts Integrated Care Market will be hiring transitional care nurses, charged with improving patients’ self-management skills and enhancing communication between the patient, healthcare delivery teams and the patient’s primary care physician. The nurse will physically and telephonically follow the patient through the entire post-acute episode of care.

      “One of the biggest challenges patients face is that they are eager to return to their previous level of function and activities after discharge from the nursing center,” said Patricia Hooley, RN, Case Manager at Kindred Transitional Care and Rehabilitation – Forestview in Wareham, Mass. “We work with them to understand that may not be possible right away, and they need to have realistic goals and expectations. A discharge from the hospital is a relief, but rehab is truly the beginning of their well-being, and rehab takes time, patience and work.”

      Ms. Hooley and the team work with patients from the time of their arrival on achieving functional goals – addressing topics as basic as showering, toileting, walking, transferring, and going up and down stairs – and, when available, the family is included in the training. Discharged patients receive follow-up in their homes from occupational and physical therapists and nursing for a few weeks and many go on to continue their rehabilitation work in an outpatient facility.

      Kindred knows that successful discharge and transition to the next setting of care is important to our patients, and it is important to us as well. Medicare has also placed an emphasis on this area of the care continuum. The following Web resources may be helpful to patients and caregivers as well:

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