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Prevent Readmissions With Discharge Planning

Rebecca Hendren, for HealthLeaders Media, April 5, 2011

“Every participant comes to the situation with their own values, their own beliefs, and what they want to get out of it,” says Popejoy. “What stands out for nurses or social workers is their overall concern for patient safety. Their input into the decision making process is to find the most reasonable choice and the safest choice.”

For older patients, most just want to go home. Some recognized they were too weak and were willing to go somewhere else, but for them, it was to be a short-term stay where they could get stronger and then ultimately go home.

For families, safety is important, but also the issue of ‘I want my parent to be able to live the life they want to live,’ says Popejoy. “For a spouse, it’s a whole different ball game—they just want their spouse to go home with them.”

Within child-parent relationships, some want their parents to live with them; others recognize that their lives are too complicated to handle a parent at home who is functionally unable to care for themselves. Some can handle a short-term stay, but not one for the long term.

Popejoy says that hospitals need to figure out who the key players are who can influence decisions. “Listen to older adults and find out what they want, but also listen to the family and what they can do,” she says.

She cautions decision makers are often not available during Monday to Friday business hours. Although most organizations know this, it can be difficult to get good information across the week, not just during traditional work days. Discharge planning and communication may have to be done via conference calls or during off hours.

Another important thing that leaves healthcare teams in difficult positions is the idea of autonomy.

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