Hospital discharge has always been a stressful time for families. Now, because of COVID, it's become even more so. Our Nurse case managers can help make sure things go as smoothly as possible and minimize the chance that your client will need to return to the hospital.

BScN, RN, GNC (C), CHPCN (C)BScN, RN, GNC(C) President,
Eldercare Home Health Inc.

This post is for Social Workers and healthcare professionals working in hospitals.

As you know, seniors who are discharged from hospital have been found to have a very high rate of re-admission.

How you can help keep things from going off the rails for your senior patients, once they return home

1. Discharge letter – Make sure you patient gets one, and whomever is there to accompany them home, also gets a copy (with permission). This will increase the likelihood that  follow up appointments will be made, medication changes are followed etc.

2. Follow up appointments – If possible, try to ensure they are booked prior to the patient leaving hospital. Visiting lab services etc. can help make this easier.

Getting to a lab for bloodwork can be a big deal for an unwell senior – they may need assistance with getting out of bed, getting dressed, meal preparation, getting down stairs, getting in and out of a vehicle etc. A visiting lab service can be worth, the small additional fee for the convenience.

3. Medications – Ensuring your patient’s medications are up to date and organized, may actually prevent a fall or readmission on its own. Make sure your client’s medications have been reviewed by the pharmacist and that a complete, up to date list is provided as part of the discharge. If your patient has a family member who can organize their meds in a dossette, or has private care where a Registered Nurse can load their dossette each week, great. If not, meds should be prepared in a blister pack by the pharmacy, wherever possible.

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4. Medical alert service – If your client lives alone, ask if you can provide them with a referral for a medical alert system like Philips LifeLine. Services will often waive the setup fee for new clients, which may make them more likely to accept the service

5. Food– It’s easy to overlook, but obviously very important. Try and find out if a family member has been to the patient’s home since they’ve been in the hospital. They should toss out all overdue items and make sure the kitchen is well stocked with fresh supplies. Healthy meals and hydration are key to getting patients back on track after a hospital visit or set-back.

About Eldercare Home Health

We’ve been working with Social Workers and Discharge Planners, and caring for seniors throughout Toronto, since 1995.

We are the only elder care service in Toronto that provides PSW care that is actively case managed by Nurse Case Managers – at no additional charge. If you have an elderly patient who needs additional care in hospital, at home or with their Hospital discharge, contact us today.

  • No-charge assessment by Registered Nurse
  • All initial assessments are conducted by a Registered Nurse, not a marketing person or “care coordinator”
  • We have a Nurse on call 24/7 for emergencies so there is always someone knowledgeable to talk with
  • All PSW caregivers are directed and supervised by Nurses – at no additional charge

FREE assessment by a Registered NurseCall Now! 416-482-8292

Don't want things to get worse?
Call Now!

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