Accessing Community Resources
There's almost nothing that seems quite as stressful to some patients and family members as facing the reality that the hospital is booting them out before they are ready to go. No matter how much time is spent on discharge planning, some are just not prepared. The patient usually doesn't believe that he would have to go so soon.
To soothe the patient and family's nerves some of the suggestions you can make to reinforce the discharge planning efforts include reviewing community resources they should enlist to help them through this crisis. Of course, their network of friends and family should be enlisted. This can be as simple as a list of people the patient could call and check in with regularly. Or a friend who could make a scheduled quick phone call to the patient once a day to remind her to take her meds.
Clergy and friends from church or other religious organizations can be good sources to network with to find caregivers and others willing to help with errands and transportation to and from appointments. They can also be a great source of emotional support to the family as well as the patient.
For seniors, local senior centers and agencies on aging can help with other resources. Have the caregiver make a visit to the senior center site and pick up all the literature the agency has available. Encourage the caregiver to share information about his situation and ask for advice. These groups have a wealth of information and resources.
The hospital may offer patient education classes and other community service education resources. The hospital may also be involved in low-cost medical transportation or hot meal delivery services. (These could also be available from the senior center.) Local chapters of organizations such as the Alzheimer's Association, American Heart Association, MS Society, American Cancer Society, etc., may be appropriate resources as well. High schools and local colleges may be resources for hiring flexible part-time help for errands, shopping, cooking, and even some companionship opportunities. A nursing program at a local college might be an excellent opportunity for both patient and employee.
Discharge planning is a team effort. Remember that the patient is an important member of that team and needs to be involved in the entire process. Effective discharge planning will help the patient assume responsibility for his care and prevent unnecessary repeat hospitalizations.
