PLANNING & SUPPORT

For the Next Level of Care or a Transition to Home

Transitioning from a stay in a skilled nursing facility can be an intimidating event for patients and their families. Everything about this transition is critical to the health and well-being of the person you care for. Studies have found that improvements in discharge planning can dramatically improve the outcome for patients as they move to the next level of care. Every patient is different, but a discharge plan will always include the following:

• Complete evaluation of the patient by qualified personnel.
• Discussion of future care with the patient and/or their care representative.
• Reconciling medications – a thorough review of prescriptions, to be certain there are no duplications, omissions, harmful side effects, or drug interactions.
• Logistics planning for homecoming or transfer to another care facility.
• Determining the need for caregiver training or additional support.
• Referral to a home care agency and/or appropriate support organizations.
• Arranging of follow-up appointments or tests if necessary.
• Ensuring you have the name and email address of your go-to person for care questions, as well as a phone number where you can get help 24 hours a day, including weekends.

Planning discussions will cover everything from the types of care that will be required and medical equipment needs, to diet and meal planning or medication administration.