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Next Step in Care: Family Caregivers & Health Care Professionals Working Together

For Health Care Providers

Discharge Planning Is a Family Affair

“Discharge Planning Is a Family Affair” gives a glimpse into how even the best-intended discharge conversation can go horribly wrong. Look for opportunities and suggestions for improvement below the video.


Opportunity: The patient’s and family caregiver’s situations could be accounted for in the discharge plan.

Suggestion: Assess the family caregiver’s needs, including availability, other responsibilities, tasks that the family caregiver can/cannot do/needs training for, and overriding worries. Integrate this information into the plan of care, thereby increasing the safety of the discharge. Use the Next Step in Care tools for assessing the needs of family caregivers.

Opportunity: The patient is being discharged with test results outstanding.

Suggestion: Provide the family caregiver with a list of pending test results, dates when the results will be available, and where those results will be sent (preferably the appropriate community provider, such as the patient’s primary care or cardiologist). Use the discharge checklist "Going Home: What You Need to Know" (see page 3) to record these with the family caregiver.

Opportunity: The family caregiver is notified of a change in medication in the final discharge conversation.

Suggestion: At admission, complete a reconciliation of all medications, OTCs, and herbals taken at home with the family caregiver, including any concerns the family caregiver may have about the medications, interactions, or scheduling. Update the medication list together with the family caregiver regularly, which reduces surprises and confusion at discharge. Use the Medication List and other tools.

There are several other opportunities for improvement in the video, and we hope you find this video helpful in identifying and addressing potential issues with your own organization’s discharge conversations, and general communication with family caregivers. This website’s resources are free and available to you.

The dialogue in this video was adapted with permission from a scenario in The Cultures of Caregiving (edited by Carol Levine & Thomas H. Murray, Johns Hopkins University Press, 2004).
 

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