Managing Transition Among Care Centers

Whether it follows a sudden stroke or heart attack, a hip fracture, or even long-planned surgery, the shift between home and hospital or from a hospital bed to a berth at a rehabilitation center can be confusing and difficult for everyone involved. The steps below can help caregivers more easily navigate the twists and turns involved in transitions.

Try to be prepared. Unexpected hospitalization is one more reason caregivers should keep an updated list of medications handy. Other useful items include contact information for primary care clinicians and specialists, insurance card numbers and financial information, and copies or originals of health care proxies, living wills, and do-not-resuscitate orders, as appropriate. By contrast, a planned hospitalization gives both patient and caregiver a chance to become even better prepared for both the hospital stay and the return home. Learn which home modifications can make familiar surroundings safe and comfortable. For example, how will front steps and inside stairs be managed? Will any daily tasks, such as dressing, bathing, eating, or cooking, be too hard for the patient to handle, at least initially? Ask whether any assistive devices or paid assistance will make life easier when the patient comes home. If rehabilitation is in the cards — as is likely after hip replacement or knee surgery — learn about the options. Visit centers to make an informed choice (see below).

Get connected. Ask a few questions right away, says Suzanne Burke, a registered nurse and senior director of case management and social work at Cambridge Health Alliance in Massachusetts. While the patient is in the hospital, who can you contact for health updates and other concerns? Should you speak to the nurse, or will a case manager be assigned? What is the best time to call? When should you expect to know the plan for each day? When does the attending physician make rounds?

Be an extra set of eyes and hands. Bring worrisome behavior or symptoms like hallucinations, troubled breathing, confusion, and depression to the attention of clinicians. Check medications to ensure that the correct ones are given. Make glasses and hearing aids available. Simple things, like warm nonslip socks and slippers, a bathrobe, and moisturizers for skin and lips, are comforting. As soon as sitting up in a chair and walks are deemed safe, help with these activities when staff members are busy. Be sure to learn safety tips for moving and walking with the person first, though. Visit at mealtimes to assist with eating and make it a more social activity.

Jot down medical questions and answers. A written list will help you stay organized and get all the answers you need once you have the ear of a busy doctor or nurse. Write down their responses, too, lest stress makes you forgetful.

Look toward the future. Always consider the next step. Will the patient go home or to a rehabilitation center? How long will rehabilitation take? How will the person feel and look when discharged? Will home health care or home modifications be necessary? Are disabilities likely to be temporary or permanent? Discuss these issues with a case manager or social worker as well as clinicians.

Visit rehabilitation centers. If your loved one needs transitional care, visit any rehabilitation centers that are recommended. Ask friends and co-workers for recommendations. A facility recommended by someone who has received care there or who has had a family member who was a patient there is one worth visiting. The patient's case manager should be able to help you set up a visit. Take a careful look at the environment: Is the facility clean and comfortable? Does the staff seem friendly and helpful? Bring along a list of questions. Ask about everything from the qualifications of the staff to the services provided to the daily routine (see "Evaluating a transitional rehab facility").