Discharge Planning

Discharge Planning

We locate the facility, explain the discharge procedure, and communicate with social workers on your behalf.

    • Evaluation of the patient is performed by an RN along with Certified Assisted Living Managers.
    • Discussion with the patient or his representative
    • Planning for homecoming or transfer to another care facility
    • Determining whether caregiver training or other support is needed
    • Referrals to a home care agency and/or appropriate support organizations in the community
    • Arranging for follow-up appointments or tests

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation, and chores; and possibly a referral to home care services.

Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care.

What should the discharge plan include?

The discharge process and plan should address the following items:
• Your loved one’s condition and any likely problems or changes that could occur at home;
• A determination of Medicare or insurance eligibility for the recommended discharge services, e.g., rehabilitation, skilled nursing, home health, adult day services;
• Establishment of home care services, and necessary equipment rentals or home modifications;
• Referral to community-based services, e.g., adult day services or case management to help coordinate and manage post-discharge services;
• A review of all medications taken prior to admission and all the medications prescribed to be taken post discharge to ensure no duplications, omissions or harmful side effects;
• A complete written medication list with dosage instructions;
• The teaching and practicing of specific patient care procedures;
• Dates and times of follow-up appointments;
• A 24-hour phone number for the caregiver to call to speak with a health care professional regarding any health and care-related concerns; and
• Transportation home.

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Senior Care Placement Testimonials

I could have not asked for better assistance and support than Senior Care Placement & Consulting Inc. Their staff not only provided emotional support, but assistance in finding the best care for my dad. My sister and I would not have been able to do this without the continuous support from Senior Care Placement. We are very grateful and appreciative.

Ms. Jazayeri    

Senior Care Placement has been a valued service to my assisted living facility. Mary and Antoinette have been very extremely helpful in providing me with referrals that help to keep my business thriving. Senior Care Placement not only is an asset to my business, it is an asset to the families who seek their assistance in finding a good facility for their love one. They go above and beyond what I have come to expect from larger placement agencies. Mary and Antoinette are compassionate and caring, they truely treat their clients as family, and help them in every step of the journey in finding the best placement to fit their needs. I would recommend their service to any facility looking to keep their beds full. They are a great asset to families and to our community. Thank you for all that you do!

D. Phillips – ALF Provider

The management of Layhill Manor shares it's high recommendation to the Senior Care Services team! We can't say enough about the selfless, professional and efficient services you provide. The care and services you provide to families during the placement process is invaluable and unparalleled in this market space. You keep your clients informed, you tour with them and are always advocating to get them the best. As a provider I am particularly thankful for your consistency and follow through. You do what you say and you make things happen! Kudos to the entire team for your heart of service and the excellent job you do partnering potential clients with the right providers. Two thumbs up! :) 

S. Dujon  & F. Baird – ALF Providers