Notes, News & Musings on Elder Care


discharge planning


Hospitalization can be a trying and difficult experience, especially for older adults.  The senior aged population is at higher risk for hospitalization and more vulnerable to encountering problems while there.  In 2010 alone, over 13.6 million adults over the age of 65 were treated and discharged from the hospital with an average length of stay at 5.5 days1.  Patients with dementia are at especially high risk for hospitalization, often with poorer outcomes and worsening cognitive status2.

A little planning and preparation can help make the hospital experience go more smoothly for patients and loved ones. Navigating through the maze of hospital settings is a little easier with a “roadmap” to follow.  By better understanding how key people and departments can help, you will also know who to turn to for assistance should you run into any bumps along your way.

The Emergency Room (ER)— The goal of ER personnel is to assess, treat, and stabilize the patient, and this process can take 4 or more hours3.  If unable to return home, the patient will be moved to a different hospital department to be admitted or observed.  (See our article on observation vs admission in our Fall 2013 newsletter for more information on this very important subject:

Since most patients enter the hospital through the ER, it is a critical point in relaying information to the healthcare team.  To make the intake process easier, some caregivers choose to keep the following information readily available to bring to the hospital.  Make sure that the hospital staff copies the records and returns the originals.

  • An up-to-date list of all medications, supplements, herbal remedies, and over-the-counter medications
  • Copies of insurance cards, Power of Attorney (POA) paperwork, and if available, Physician Orders for Scope of Treatment (POST form)
  • A list of allergies and general medical history including any recent changes and past surgeries

Now is not the time to downplay symptoms.  Give details on pain levels, symptoms, and any recent changes in health or medications.  Since many primary care physicians (PCPs) and specialists are associated with hospitals, be sure to mention any doctors seen recently.  The ER may be able to access records online through a healthcare portal.  This information together with symptom information will help the doctor to diagnose the patient appropriately and to suggest treatment options.

Patients with dementia need special attention in ER settings and all-too-often do not receive it.  ERs are anxiety producing, busy places that can be confusing.  The experience can be improved by having someone present—either a loved one or hired personal care attendant–who can help calm the patient’s nerves, answer questions, and offer reassurance.

The PIN number—Many hospital settings have changed their rules about providing private health information to friends and family.  In most hospitals a 4 digit code is set that allows those who know it to receive updates from hospital staff.

There is also an option to set privacy settings with the hospital as a “no information patient”.  This will mean that when people call the main line of the hospital and ask for the patient’s room number the operator will say that there is no one at the hospital by that name.

Intensive Care Unit (ICU)—ICU departments have rules and regulations that are different from other areas of the hospital.  Admission of children as visitors (even in the waiting room) is much more restricted, as are visiting hours and numbers of visitors.  If the patient has dementia or is easily confused, we recommend talking with the ICU staff about allowing a loved one or hired personal care attendant to remain with him or her at all times.  Often ICU staff will be somewhat flexible in an effort to help accommodate patient needs such as these.

The Treatment Team—Once admitted, doctors, nurses, and additional services such as respiratory care and physical therapy will meet with the patient for a review of care needs and treatment options.  This “treatment team” will decide treatment goals, estimated length of hospital stay, and discharge needs and options.  Some of the lesser known but very important members of the team are listed below:

  • The Nurse Caseworker or Utilization Review Nurse—This person works with the insurance company to decide to what extent and how long care will last. If there is a question or concern about admission status or length of stay, this is a good person to ask.
  • The Discharge Planner—We view this person as one of the most important members of the treatment team because he or she will work with the patient and family on nursing home and rehab (skilled care) options. Try to speak with or leave a voicemail for the discharge planner about preferences as soon as possible. Many nursing homes and rehab facilities have long waiting lists, but hospital patients receive priority on those lists.  If the discharge planner contacts the patient’s top picks earlier rather than later, there is a higher chance of receiving a preferred aftercare placement.   Discharge planners usually do not work weekends.
  • The Patient Liaison—Not every hospitalization goes according to plan and sometimes problems need to be addressed. If there are problems that have not been easily resolved, ask to speak with the patient liaison for assistance.
  • Dietary Staff—One of the biggest complaints that we hear about hospitals is that the food is less than delicious. Many people are unaware that patients can make special requests for favorite foods and can request a different meal tray if what is served is not appealing.  Remember that dietary staff must work within the dietary orders given by the doctor (so they can’t serve a huge slice of chocolate cake if the patient is on a diabetic diet!).  Snacks and drinks are also available through the aides and nurses on your floor.

DischargingNo matter how quickly the patient wants to leave the hospital, it is important to thoroughly review discharge paperwork and instructions.  It is much easier to correct any mistakes and receive clarification on discharge instructions now rather than doing so over the phone later.  Review the medication list and double check that it is accurate and that medication instructions are understood.  Make sure the doctor leaves any prescriptions that will be needed and any orders for home health, physical therapy, or lab work.  Work with the nurse and discharge planner on any follow up appointments.  If given an option, make appointments yourself so that they can be scheduled at convenient times.  If transportation is needed for follow up appointments, speak with the discharge planner about options.  Ask that the patient’s medical records from the hospital stay be sent to any physicians who will be seen for follow up.

A few other pointers

  • As part of the Life Care Plan Services through our office, Elder Care Coordinators are available to help with advocacy, referrals, and communication with the hospital treatment team. Do not hesitate to contact us!
  • Review the CDC document “6 Ways to Be a Safe Patient” found at for tips on reducing healthcare associated infections. Do not hesitate to ask hospital staff to wash their hands upon entering your room.
  • Be polite but assertive. Quality and speed of care ought not depend on how nice a patient is, but as the old saying goes, “you can draw more flies with honey than vinegar.”  Say “please” and “thank you” and remember The Golden Rule.  For exceptional staff, speak with a supervisor or write up a rave review to commend him or her for excellence.  If there is a problem with a staff member, request a transfer to a different team member for care.
  • “Where everybody knows your name…” Hospital staff get in the habit of calling patients by room numbers.  It is human nature to feel more connected to people whose names we know.  Get in the habit of making introductions with staff members as they come into the room and try to call them by their names—they will most likely reciprocate.  Maybe there shouldn’t be, but there is a difference in the way a person reacts to “Room 213 needs a pain pill” and “Mrs. Jones needs a pain pill”.
  • Don’t pack for a trip overseas. Remember that the more that is brought to the hospital, the more must come home.  It is especially important to leave expensive items such as jewelry, watches, purse/wallet, and laptops/tablets at home.  If the patient prefers to be in his or her own clothes, consider something easy to get on and off and will be comfortable for both day and night.
  • Boundaries are important for visitors. It is important for visitors to respect the privacy of loved ones and others in hospital settings by not posting photos or personal information on Facebook or other social media sites.  Balance the need to be present and support the patient with the patient’s need to rest and receive care and treatment from staff.  Don’t hesitate to show appreciation on behalf of the patient—staff almost always appreciate a treat like donuts or a fruit basket.  Note that staff in healthcare facilities cannot ethically receive personal gifts and should NEVER ask for any gifts.  The exception to this rule in most settings is if a gift of food is made to the team or unit.
  • Abuse or inappropriate behaviors. Unfortunately abuse and inappropriate behaviors do happen in hospital settings.  If there is a questionable behavior, immediately speak with hospital leadership and/or your area ombudsman.  If there is a question of abuse, contact the police.


  1. National Hospital Discharge Survey. (2010). CDC.  Retrieved from
  2. Phelan EA, Borson S, Grothaus L, Balch S, Larson EB.Association of incident dementia with hospitalizations. (2012, Jan 11) JAMA. 307(2):165-72.
  3. Emergency department pulse report: Patient perspectives on American health care. (2010). Press Ganey.  Retrieved from

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