November 20, 2016
During the 10 years that I took care of
both my parents, there were many visits to many hospitals for
When it was time for their discharge,
doctors, nurses and social workers barraged us with care
instructions, prescriptions and physical therapy scripts.
was told different Medicare approved agencies would be calling us to
arrange for assessments and care visits. Most of it went in my one
ear and out the other. It was overwhelming, intimidating and scary
for me as their caregiver to think that I might do something wrong
and land them back in the hospital.
Today, individuals are
discharged from a hospital much sooner and hospitals are encouraged
not to have re-admissions because they could lose federal funding.
Hence, the “observation stay” that puts individuals in limbo and can
sometimes deny them Medicare coverage if they need rehabilitation.
This is a very important issue to discuss with a hospital if your
loved one needs to go into a facility after they are discharged.
In order to maintain low re-admission rates and assure quality
care after a discharge, hospitals are establishing guidelines and
programs for “transition” care. This new approach was prompted by
the passage of the CARE Act that took effect in April.
stands for Caregiver Advise, Record, Enable. It updates New York’s
public health law and “requires hospitals, at a patient’s request,
to provide discharge instructions and post-release care plans to a
This act was designed to assist the
four million NYS families who serve as caregivers so that their
loved ones can stay in their own homes and hopefully not re-enter a
hospital or be admitted into a nursing home.
State Sen. James
L. Seward (R/C/I-Oneonta), a co-sponsor of the bill, stated that
“when an individual leaves the hospital, there are a number of steps
to recovery, and quite often a loved one, without formal medical
training, is called upon to help make sure that recovery goes well.”
The Pulse publication, in its Oct. 27, 2015, ran an article by
writer Claire Hughes that states that CARE permits a hospital
patient to list a family caregiver in his/her medical records. “The
designated caregiver must be given information before a patient is
discharged, including instructions and demonstration of tasks they
will be expected to perform at home.”
According to AARP, the bill
features three important provisions:
• The name of the family
caregiver is recorded when a loved one is admitted into a hospital
or rehabilitation facility;
• The family caregiver is notified if
the loved one is to be discharged to another facility or back home;
• The facility must provide an explanation and live
instruction of the medical tasks — such as medication management,
injections, wound care, and transfers — that the family caregiver
will perform at home.
Local hospitals are actively developing
their transition care units.
Strong Memorial Hospital started
a “Virtual Care Unit” that concentrates on getting a patient through
the precarious first 30 days after a hospital discharge.
VCU team “works closely with social workers to pre-empt potential
stumbling blocks (e.g., trouble securing transportation to and from
follow-up appointments); hand-selects supplemental transition
coaching and telehealth programs administered by Visiting Nurse
Service; and conducts one- and three-week-post-discharge “rounding”
meetings — multidisciplinary huddles that ensure fluid, frequent
communication between outpatient care managers and the hospital’s
cast of health care professionals.”
SUNY Upstate Medical
Center recently created a department of transitional care. Diane
Nanno, department director, stated, “A patient that leaves the
hospital is still our patient, the care we provide extends beyond
the building walls…Our patients are members of our community and we
want to take care of them. It’s not just about getting people out
the door, it’s about providing quality outcomes and quality of
Transition care teams generally “consist of social
workers, case managers, continuum of care coordinators and patient
educators who work in collaboration with all disciplines such as
physicians, pharmacists, and therapists in an effort to help
families make informed decisions regarding care.” Establishing
relationships with post-acute providers is also a critical part of
the process after a discharge.
As our population ages, there
will be more individuals transitioning from a hospital stay to their
homes. It is imperative that our health care system deal with the
challenges and uncertainty faced by patients and their caregivers.
The CARE act is intended to be a first step in that direction.
In thinking about my parents when they were in the hospital, all
they wanted was to return home and all I wanted for them was to be
home — secure, unafraid and getting healthy. As caregivers, we no
longer have to feel insecure. We now have the support and guidance
to provide a safe environment and quality of life for our loved ones
when they return home from a hospital stay.