Helping My Grandmother Return Home

Dear Doctor Marion:

My 92 year old grandmother was recently currently hospitalized for a mini-stroke from which she is recovering very nicely, and I am trying to get her homecare services before she is released so she can return home. She currently has a home attendant 7 days a week, 8 hours a day, and needs additional home care attendant hours (two 12-hour shifts), as well as in-home physical therapy and someone to assist her with taking her daily meds.  I have spoken with the hospital social worker who informed me that it may take a few months before such services are in place, which I believe should not be the case, and which means my grandmother may be released without the services needed.  Putting her in a rehab will make her more disoriented than allowing her to return home. I have spoken to the attending neurologist who agrees she needs the additional assistance and have put my request in writing to the hospital social woker handling her case.  Can you inform me on how I can further advocate on her behalf, or rather, the next steps I should take to make sure she receives the necessary services in her home upon being released from the hospital?  Thank you in advance for your advice.

Lorena in Texas, 41

Dear Lorena,

Your grandmother is truly blessed to have someone be her advocate. When dealing with discharge from any institutional setting, be it hospital, rehabilitation or other, all of the required services need to be in place before  returning home. These services include the necessary equipment such as a hospital bed, wheelchair, walker, bed rails and other safety rails.

Also, you need to make sure that the discharge plan takes into account all of the  required support (such as aides) and how the services will be paid for. Will there be a continuation of physical or occupational therapy, and if so, how often, and for what duration of time for each appointment, and will there be a visiting nurse as part of this? Will these services/therapies come to the home or will your grandmother have to go to a specific location?

Upon discharge, you need to know about any new regime of medications and if your grandmother will be given a few days worth of medication or just the prescriptions.  And finally, find out who is arranging the transportation for going from the hospital to the home setting. Taking time to deal with all of these issues with the Discharge Planner will make everything much more harmonious.

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