Discharge & Follow-up 

Discharge follow up
A trip to the hospital can be an intimidating event for patients and their families. As a caregiver, you are focused completely on your family member’s medical treatment, and so is the hospital staff. You might not be giving much thought to what happens when you or your relative leaves the hospital. Patients, family caregivers and healthcare providers all play roles in maintaining a patient’s health after discharge.

What is discharge planning?
Medicare says discharge planning is “A process used to decide what a patient needs for a smooth move from one level of care to another.” Only a doctor can authorize a patient’s release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager or other person. Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach.

In general, the basics of a discharge plan are:

• Evaluation of the patient by qualified personnel
• Discussion with the patient or his representative
• Planning for homecoming or transfer to another care facility
• Determining if caregiver training or other support is needed
• Referrals to home care agency and/or appropriate support organizations in the community
• Arranging for follow-up appointments or tests.

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home.

Assurance Health Post-Discharge Follow-Up
Our 2-week post-discharge follow-up is an essential part of patient treatment success. It allows the patient’s actions, questions, and misunderstandings, including discrepancies in the discharge plan, to be identified and addressed, as well as any concerns from caregivers or family members. Discharge follow up is completed by an Assurance Health nurse or social worker approximately two weeks after discharge.

This follow up serves dual purposes. First, this is done to ensure the progress you or your loved one made while at Assurance Health generalizes back into the home environment. Second, the nurse or social worker has capacity to answer questions, provide resources and recommendations if you or your loved one is again experiencing difficulty.

Callers review each patient’s:

• Health status
• Medicines
• Appointments
• Home services
• Plan for what to do if a problem arises