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

Home to Hospital

The Provider's Perspective

Whether your patient was admitted to the hospital for a planned procedure or came from the ER, as a health care provider your goals include planning for the next step in care. To do that effectively, you need the collaboration of the patient and his or her family caregiver as well as other members of the health care team.

The materials and guides available on this website can help. A useful way to think about the process is to divide the hospital experience into three segments: admission, planning for discharge, and discharge.

Upon admission, health care professionals must obtain necessary information in order to diagnose, treat, and create a plan of care. Identifying your patient’s family caregiver and discussing the situation with him or her can be an important source of vital information about the patient--what brought him or her to the hospital, previous hospitalizations, current medications, and other conditions that may affect care.

Planning for discharge in many cases happens immediately after admission. Family caregivers often have an ongoing responsibility for provision and/or coordination of care after the discharge. To be effective partners, they must be included in the process, given necessary information, and have their needs as well as those of the patient considered in a collaborative decision-making process.

The discharge itself is often rushed and complicated and requires a high level of coordination. Discussing the details of the discharge plan and needs for follow-up care with family caregivers is essential and can assure a smoother transition and continuity of care.

The guides and checklists available in this section can help you facilitate such discussions. They are organized to reflect the needs of both family caregivers and health care professionals during admission, planning for discharge, the discharge, and follow-up care at home.

In addition to the family caregiver guides, there are specific guides for health care providers to help you understand the family caregiver perspective. These are HIPAA, Medication Management, Assessing Family Caregivers' Needs, Reducing the Stress of Hospitalization on Patients with Dementia and Their Family Caregivers, and Hospital Discharge Planning.

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