Leaving the Hospital: Your Hat, Coat and Discharge Papers

Leaving the Hospital: Your Hat, Coat and Discharge Papers

Recently a client was discharged from a hospital here in Westchester County. He was brought to the ER from his assisted living residence as a result of complaints of dizziness and unexplained confusion. As the trip to the hospital occurred in the middle of the night, for reasons I will never understand, the necessary list of his current medications were not given to the EMS driver, or the driver neglected to give them to the ER department. When he was ultimately discharged from the hospital (a diagnosis of dehydration), the discharge medication list bore little resemblance to the medications he was taking at his residence. His longtime doctor surmised in lieu of not having a current medication list, the hospital relied on medication records from years before. What occurred was inexcusable. Yet, if it wasn’t for the discharge summary that accompanied him back to his residence, this medication tsunami would never have come to light. Discharge summaries, which are given to the patient or family at the time of departure, are essential for a smooth transition to wherever the patient will be going.

A hospital will discharge a patient when they no longer need to receive care within the confines of a hospital. Because hospitals follow formularies set forth by Federal guidelines, discharge can occur before a family believes their relative is ready. The family has the right to appeal the discharge by calling the Quality Improvement Organization (QIO) Livanta at 1-866-815-5440. An independent determination is made within 24 hours and if discharge is to occur, the patient has to be out of the hospital by 11AM the following day. But assuming the discharge is occurring at a safe and appropriate time in the recuperation process, discharge summaries are essential. A discharge planner will stop by the patient’s room and meet with the patient, the family or significant others and help to coordinate the care one will need after leaving the hospital. If rehabilitation is necessary, the discharge planner will have already asked for the names of three to five rehabilitation centers that are situated in nursing homes. The services of an elder care consultant or an aging life care specialist can be extremely helpful at this juncture as we are familiar with those rehabilitation centers that provide quality care.

One should bear in mind, that even though a loved one may be discharged from the hospital it may not mean that he is fully recovered. The person may need a lesser level of care that the hospital has determined can be provided at home with or without the services of a visiting nurse. If a person is in the hospital for a day or so and is otherwise in good health, there may be no need for any type of nursing care once home. The discharge planner, who is usually a nurse, will explain this. However, if the patient came into the hospital and was already compromised medically, chances are their discharge papers will indicate that a visiting nurse will be coming to the home within 24-48 hours after discharge. The nurse will do an assessment to determine what kind of follow-up services are needed by the person including physical therapy. If there is a need for medical equipment, the visiting nurse will assist the patient and family in obtaining what we call DME: durable medical equipment. It will be ordered from those sources that are designated as Medicare providers. If a family chooses to go to a source not recognized by Medicare, they will pay out of pocket for such equipment such as a commode, walker, or bedrails.

The discharge papers will also list medications. Sometimes a patient will leave the hospital and continue on the same medications he was on before. Other times, based on a new diagnosis, a medication will be eliminated and another one started. Usually, the discharge planner will call in the new prescriptions to the person’s pharmacy. With these medication changes and possible new diagnoses, the discharge papers will tell you what doctors followed the patient in the hospital and who the patient should follow-up with after discharge. Unfortunately, when the directions are to follow-up with an internist in a week or ten days, it may be challenging to get an appointment within that time period. I have found here in Westchester County one can wait weeks for the discharged patient to see their internist. If the discharge papers read to follow-up with a specialist, and you are a new patient, the wait can even be longer.

If time permits, prior to the discharge, the patient and the family should compile a list of questions they have about next steps. It is essential to keep in mind that discharge planners are working under a timeline. When those discharge papers say it’s time to leave, it’s time to leave. Paying out of pocket for even an extra day can cost thousands of dollars.

As Rare as Venus Passing Across the Face of the Sun

As Rare as Venus Passing Across the Face of the Sun

On June 5th and 6th 2012, the world was able to witness planet Venus passing across the face of the sun for about 6 hours causing a small black dot to appear on the sun’s surface. This event will not reoccur until 2117. I didn’t see the passing in 2012, and I can confidently say I will not see it in 2117. Yet in my world of being a geriatric consultant, I did see something equally as extraordinary. A senior adult called this Aging Life Care® Consultant to inquire about my services and how I might, one day, help her. A senior adult inquiring about help for herself, as rare as Venus passing across the sun.

This call was a first for me. I was accustomed to counseling adult children in such matters as dementia, in-home and residential alternatives, and overcoming parental resistance. I asked Isabel (not her real name) what prompted her call. She explained that her adult children lived at a distance, and she wanted to prepare for whatever the future may hold. She was 84. There was nothing compelling going on at the time, so I described how I could potentially be of help. A year later, I heard back from Isabel. She asked that I come to her home so that she could meet me and vice versa. Two years passed before I heard from her again, this time she asked if I could help her find a companion for a couple of days a week. Because I had done what we call in the trade, “a meet and greet,” I had a good idea of what type of companion would work best with her. Luckily, she was available, and the match was a successful one.

The passage of time brought conditions that required more care and eventually the need for a fulltime companion. None of this lessened Isabel’s astuteness to her needs, especially her hearing loss which was impacting on the activities she enjoyed in the community and with friends and families.  I am accustomed to seniors finding less effective and more irritating hearing solutions telling others: “To just speak louder.” Not Isabel. In keeping with this proactive senior, she headed to an audiologist to be fitted for hearing aids. They have helped, but even with regular adjustments, not to the degree she hoped.

With her mood now wavering and her age passing 88, we spoke about how the diverse world she was accustomed to was receding. Her family suggested consulting with her doctor about an anti-depressant which Isabel thought might be helpful (Again, I am more familiar with the response: “who needs that, I’m not crazy”). Not surprisingly, Isabel also asked me to recommend books about getting older. I mean getting older…. the real McCoy. Step aside Nora Ephron. The vicissitudes of accepting that you have less days on this earth than more. And with some research I shared three books with Isabel that would support what she was feeling.

  • Still Here: Embracing Aging, Changing, and Dying 
  • Growing Old: Notes on Aging with Something Like Grace
  • Helping Yourself Grow Old: Things I Said to Myself When I Was Almost Ninety

 Currently, Isabel and I chat on a regularly irregular basis. Sometimes short because a Zoom is about to start, other times longer. She leads me. I always like to know what she is reading, and we exchange names of books we have enjoyed. Truth be told, some of her nonfiction book recommendations are beyond my comprehension.

As an eldercare consultant I have always felt in the giving, there is receiving. It is so much the case with Isabel. And when the opportunity presents itself, I always remind her that she is my role model. I am not waiting for Venus to pass across the sun.

ADL’s and IADL’s: The Alphabet of Assessing an Adult Senior

ADL’s and IADL’s: The Alphabet of Assessing an Adult Senior

Where does this geriatric care manager start when a family is eager to help an aging parent?  The answer is an assessment. It is a bevy of questions that are asked to determine how best to approach the issues at hand. Some of the questions I ask are unique to the situation, but others are basic: Activities of Daily Living aka ADL’s and Instrumental Activities of Daily Living aka IADL.

Activities of Daily Living tell about an adult senior’s ability for self-care. Is a parent able to feed herself? This does not include preparing a meal or even chewing or swallowing the food, it is bringing food to one’s mouth. Dress and undressing without assistance, from underwear to shirt and tie.  Toileting: is the older adult able to ambulate independently or with a walker or wheelchair to the toilet?  Transferring:  can the person independently move from one place to another, from a bed to a chair?  Personal hygiene: can an older person bathe themselves, brush their hair, their teeth?

While the Activities of daily living provide a gauge as to whether an adult can live safely on their own, the Instrumental Activities of Daily Living, are also of important consideration. IADL’s include the ability to manage money this would include paying bills in a timely manner. The ability to go grocery shopping or to use a food delivery service. Getting to and from doctors’ appointments.  Household chores including doing laundry, hand washed or otherwise, and selective house cleaning.

Beyond these two significant areas, an assessment will look at the finances of the older adult to determine if there can be alternate living arrangements or home care paid for privately or thru an entitlement program. Knowing about family support within the geographic area in which the older adult resides is important. The role that can be played by adult children living at a distance. The physical, emotional and cognitive conditions the senior may be confronting, and the ability to take the corresponding medications responsibly. The “story” of the senior’s life. Personality traits, occupation, significant events that may influence how best to approach a parent. Who might it be in the family or beyond the family that may have the greatest chance of influencing the senior?

By combining responses to ADL’s, IADL’s, and the topics discussed above, this geriatric care manager can help families take the first step to bringing a parent to a healthier and safer way of living.  To this end, health care directives and a power of attorney should be in place to ensure that next steps can be taken without complications.

The Anatomy of an Appetite: Aging and Our Relationship to Food

The Anatomy of an Appetite: Aging and Our Relationship to Food

Many of life’s events involve food. From the grandest of celebrations to the smallest of gatherings, there is always a place for food. As an Aging Life Care Professional®, I recall a wonderful get together this care manager had organized to celebrate a client’s birthday, her ninetieth… I thought.  She so enjoyed her birthday cake. It was only after I re-did the math that I realized my enthusiasm was premature; Dorothy had another twelve months to go to before she reached her 90th year.

Dorothy took great pleasure in eating her birthday cake. But such enthusiasm for food is not shared by all adult seniors.  There are a variety of factors that may contribute to a decrease in appetite: the side effects of a medication, dentures that do not fit, loss of taste, feelings of loneliness as a senior sits down to a table for one and a myriad of medical conditions.  A wince as an older adult bites into an apple or a change in appetite after the start of a new medication are symptoms that may require a visit to the dentist or a call to the prescribing doctor.

The potential for resolving the nutritional problem described above are far more likely than the changes an adult senior experiences as the end of life approaches.  He or she may lessen their food intake and ultimately refuse all nourishment. Family members are justly concerned, confused and frequently feel guilty.  Often, they fear they are starving a loved one to death if food, liquid or some form of artificial nutrition is not provided.  For an adult senior with advanced dementia, the scenario is made more complex.  As the dementia progresses it impacts on that part of the brain that controls swallowing. The chance of choking increases. In either of these scenarios it is important to recognize as the end of life nears the body adjusts to the slowing down process and minimal amounts of nutrition or liquids are needed, if at all. Now the focus becomes comfort care. Moistening the mouth with a special sponge, applying lip balm or offering a small amount of water through a straw, teaspoon or syringe.

Aging Life Care Professionals understand that while parents may have left specific directives for no heroic measures, a daughter may find it too cruel to discontinue nourishment or fluids. A son may hope for a last-minute miracle or a spouse may feel that only time will dictate when to say the last good-bye.  As Aging Life Care Professionals, it is our role to hold the hand of our client and reach out our other hand to support the family in whatever their decision may be.

Miriam Zucker, LMSW, ACSW, C-ASWCM, is the founder of Directions in Aging based in New Rochelle, New York. For over two decades she has assisted families in customizing plans of care and developing effective strategies to meet the needs of older adults. She has recently been appointed to the board of directors of New Rochelle Cares, a non-for profit organization devoted to helping senior adults live safely and fully at home.

This blog is for informational purposes only and does not constitute, nor is it intended to be a substitute for, professional advice, diagnosis, or treatment. Information on this blog does not necessarily reflect official positions of the Aging Life Care Association® and is provided “as is” without warranty. Always consult with a qualified professional with any particular questions you may have regarding your or a family member’s needs.

Can an Adult Senior Remain at Home? …That is the Question

Can an Adult Senior Remain at Home? …That is the Question

As an eldercare consultant, I am familiar with the statistic that close to 90% of adult seniors, have expressed a desire to remain in their homes for as long as possible. The terminology in the world of eldercare is “aging in place.”

My lack of surprise about aging at home, while corroborated by AARP, has its source in the adult children who visit my office frustrated that their parents feel there is no compelling reason for them to move out of their house. A typical scenario as described by a son or daughter: no bathroom or only a half bathroom on the main floor, stairs that must be ascended or descended to get to the kitchen, no direct access to the outside without holding on to a hand rail that is unstable accompanied by a walkway that is crumbling, nonstop repairs both large and small.

Sitting across from these adult children, I understand their unease. They are often wakeful at night, distracted at work, consumed with the responsibilities of calling the plumber, roofer or making sure a path has been shoveled after a snowstorm.  I also know from talking with adult seniors the comfort that comes with continuing to reside in a lifelong home. Change is never easy or welcomed.  So, what’s an eldercare consultant to do?

For this consultant, the major consideration is safety. There is no compromise on this issue. To ensure this safety there are three necessary requirements. First, the willingness of a parent to agree to whatever modifications should be made to the house. First, the readiness of the parent to accept home care if necessary and first, the financial wherewithal and/or community support services to achieve these outcomes.  Yes, they are all number one priorities.

To this end, I frequently visit the parents in their home. Often, mom and dad need to be heard and understood, with a focus on empathy. Once they know I understand their situation, it is easier to start to effect change. The secret is small steps. With each step, it is validating their willingness to undertake necessary changes. That validation provides the incentive for the next step until a safe living environment is accomplished.

But please don’t think I come with a magic wand. Sometimes the ideal, or even close to it, becomes unachievable. It may be the staunch autonomy of a parent or it is the symbiotic relationship of husband and wife who create such a strong wall (yes, this one is achievable), that adult children, the family favorite, or even this eldercare consultant cannot convince them that they are putting their safety at risk. Then Father Time steps in and removes aging at home as a choice. A fall, noncompliance with medication, or one of those all too frequent storms we’ve been having here in Westchester County, may result in a whole new aging in place definition and destination.

From Hospital to Home:  Post Hospital Syndrome

From Hospital to Home: Post Hospital Syndrome

Recently I addressed the Post-Acute Care Continuum in White Plains, New York. An organization whose goal is to educate and share best practices in post-acute care and care transitions. I was asked to speak about how geriatric care managers can help to ensure that patients return home and remain home beyond the initial 30-day period. Of course, we do not want our clients to return to the hospital at any time, but there is a reason for the specific 30 days.  In 2013, the United States Department of Health started to penalize hospitals for re-admission of patients within thirty days. The Department of Health wanted patients to be discharged responsibly with adequate follow-up care, hence this law was enacted.

Because of this act, the rate of 30-day re-admission has dropped from 20% to 17%. But often, while the reason for hospitalization has been addressed, the consequences of a hospitalization are just being felt when our clients return home. Dr. Harlan Krumholtz, MD of Yale-New Haven Hospital refers to this return as the Post Hospital Syndrome. He attributes this re-admission within 30 days to five major factors:

  1. Sleep deprivation: The patient is in a new environment. The illness combined with being in a different bed, in a different place will impact on cognitive and physical performance. A situation of perpetual jet lag has been created.
  2. Malnourishment: Certain tests and procedures require nothing by mouth for the day or evening prior. And if the test is cancelled and then rescheduled, another period goes by without nutrition. This results in protein-energy malnutrition. The consequences of such a scenario is that wound healing is impaired, there is a chance of increased infection and one’s immune system is compromised.
  3. Pain and discomfort: For any of us, especially those dealing with pain in the hospital environment, pain can lead to sleep disruption, mood disturbance, impaired cognitive functioning and may also impact on the immune system.
  4. Altering medications: Stopping one medication and adding another can have its impact on cognition and physical functioning: too much of a medication, too little, the wrong medication, an allergic reaction to a medication. A patient’s body becomes a roller coaster of experimentation in an effort to cure.
  5. Deconditioning: Time in bed for rest can put a patient at greater risk of accidents and falls. While physical therapy may take place in the hospital, Dr. Krumholtz questions if there is still too much inactivity. The result being once the patient returns home he or she is at greater risk for developing blood clots.

As discharge approaches, what must be done is a TOTAL evaluation of the patient. This evaluation should go beyond the reason for hospitalization. Attention must be given to sleep, nutrition, activity, strength and how all symptoms are treated and managed. As a geriatric care manager, it is my responsibility to observe, question and advocate for clients whose care has been entrusted to me.