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

Hospital to Home

The Provider's Perspective

The transition from hospital to home is complex and requires careful planning and coordination. Caring for a chronically ill or disabled patient at home is a complex task. Many of the tasks that were previously performed by health care professionals in the hospital will now become the family caregiver’s responsibility. Your assistance and guidance help prepare them to perform these tasks at home and assure a safer and smoother transition.

The materials created in this section address the family caregiver’s needs for information and assistance when planning for discharge and the actual discharge from hospital, and the materials related to admission, planning for discharge, and the discharge from home care services. They can also be helpful when formal home care is not involved.

Planning for discharge from the hospital 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.

Upon admission to home care, health care professionals must obtain necessary information in order to 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 happened during the hospitalizations process, current medications, and other conditions that may affect care.

Planning for discharge from home care is a critical stage for the family caregiver and the patient. Family caregivers will carry most, if not all, the responsibility for care coordination and care provision. The needs of both the family caregiver and their family member need to be considered when planning for discharge and follow up care. Family caregivers need to have information about community services and other care possibilities.

Upon discharge from home care family caregivers need to have up-to-date information about their family member’s medications, and plan of care.

These guides are designed to facilitate discussions between family caregivers and health care professionals so that transitions in care can be better coordinated, smother and safer. Each of the guides and forms can be downloaded and printed.

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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