When your elderly mum or dad has just been discharged from hospital, you want their transition back home or to an aged care facility to go smoothly. Success depends on their hospital discharge plan but you can also do plenty to help.

“Overall, we haven’t seen a big improvement [after discharge] over time, but the type of patients going into hospital are more complex and their needs are much greater,” says Dr Frances Batchelor, Director of Clinical Gerontology at the National Ageing Research Institute.

Lack of communication, not involving older people and their carers, nor having timely access to services and support are the three most common mistakes in discharge planning. Batchelor says a recent successful pilot project at Melbourne’s Royal Alfred Hospital saw discharge patients given a USB drive with a video of their healthcare team explaining the plan to them.

According to the Australian & New Zealand Society for Geriatric Medicine (ANZSGM), research studies show a third of patients didn’t know they were being discharged until the actual day, and one in ten said they weren’t given enough information when discharged. Australia’s lack of an integrated health records system doesn’t help either.

The society’s president, Associate Professor Eddy Strivens, says care transitions have become “a bit more difficult as length of [hospital] stay decreases and co-morbidity increases”.

“We’re trying to wrap the right sort of care around complex needs, so don’t leave hospital without a discharge summary in your hand. Get involved in planning for any follow-up community services and medication changes. The success of a discharge plan comes from open communication, so pick up the phone and talk to the GP.”

Get involved in discharge planning early
Carers, family members, and the patient themselves should be involved while the plan is being drafted — before the patient leaves hospital or even before admission if possible, says Gai Lander.

The now-retired gerontic practitioner developed workshops in rural NSW on how to prepare discharge plans. The four major areas for discharge planning are assessment, planning, implementation, and evaluation.

“The plan is not just for doctors, physiotherapists, social workers, community, or district nurses, for example. The patient’s personal network is a very important factor in the discharge planning process, and for their physical healing and emotional wellbeing,” she says.

Looking after the whole person
Lander makes the distinction between clinical and gerontic care: “Too often, clinic staff will just look at the patient’s medical condition — they won’t look at the total patient. For discharge planning, look at the whole person: their physical, emotional, and mental issues as well as taking into account the strength of their family and community networks.”

Pace out the transition to home
Before they are discharged, visit your parent’s home to evaluate possible issues they may face, says Sydney-based manual handling expert Aideen Gallagher of Risk Managed.

“When someone’s weak from a hospital stay, they might not be able to do as much for themselves as normal. Know where to park your car nearby at the hospital, then at their home, check the pathways, reduce clutter, and work out where you’ll help them sit down when they first get into the home. How will they walk to the toilet and sit down, or get in and out of the shower or bed? If there are difficulties, carers may have to help more and that’s when people can get injured,” she says.

Carers commonly get injured helping people out of bed or a chair if the person cannot do enough for himself or herself. Can your parent push themselves that first 30 degrees off the bed from a lying position? If not, Gallagher encourages you source equipment to help rather than lifting. A height-adjusted bed, lever, or pole to grip could assist. A toilet commode or shower commode chair are also useful.

Home care services
There’s been a shift in demand from residential-based care, such as in aged care hostels or nursing homes, to home-based care, which is cheaper for the government to fund. Even in metro areas, there may be a wait for home-care services to help older people live independently.

Nationwide, more than 100,000 people are on the waiting list for appropriate care — and some of them have been on the list for more than a year. Despite this, what you can do to help your older parent transition back into their community is to keep talking to health and allied health professionals.

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