Nova Health
NOVA HEALTHHome nursing and physiotherapy
Caregiver resources · Hospital discharge

Preparing an Older Person for Hospital Discharge

Discharge is the checkpoint with the greatest time pressure in the whole care journey. From the doctor deciding on discharge to actually bringing the older person home there are usually only a few days, and what has to be dealt with spans the hospital, the Social Welfare Department and the home. This page breaks it down by the actual process: what happens at each step, who is responsible and where family members can have an effect.

Five steps from discharge to bringing the older person home

Many family members think discharge is just one formality, but it is a whole process. Knowing clearly who is responsible for each step shows where you should follow up.

  1. 1
    The doctor makes the discharge decision
    The treating doctor decides when the older person is discharged according to the clinical condition, and usually tells the family during the ward round. After receiving the notice, the family should ask at once for the expected discharge date. It is also important to learn the older person’s mobility at discharge, for example whether the older person can walk alone, needs a wheelchair or needs to stay in bed. All the discharge preparation afterward has to be arranged according to the older person’s mobility.
  2. 2
    Meet the medical social worker (if needed)
    If the family has too little help for care, the home is unsuitable, there are financial difficulties, or long-term care arrangements are being considered, they should ask the ward nurse to arrange a meeting with the medical social worker. The medical social worker can help refer to community services, and can also start the assessment and referral process for subsidised services. Social workers have many cases and little time, however, so it is best for family members to prepare specific questions before meeting, which makes the conversation much more efficient.
  3. 3
    Hospital staff explain: medicines, follow-up, warning signs
    On the day of discharge the family receives the medicines and the follow-up slips. At this point, three things must be asked of the medical staff. The first is whether new and old medicines overlap. The second is whether follow-up dates for the different specialties clash. The third is which symptoms mean seeking medical help early. Asking face to face while still in the ward gets the most complete answers.
  4. 4
    Preparing the home
    The family should rearrange the home according to the older person’s actual ability at discharge. This includes deciding the position of the bed, clearing clutter from walkways, adding non-slip surfaces and grab bars in the bathroom, and preparing lighting for the night. If the older person’s mobility is clearly worse than before, aids such as a commode chair, walking frame and wheelchair should be rented or bought before discharge, and not arranged in a rush after the older person is home.
  5. 5
    The first two weeks at home
    The gap in the older person’s abilities only really shows in the first few days at home, and this is also the period of highest risk for falls and readmission. Someone must be nearby in the first few days at home to observe whether the older person is steady when standing up, whether any medicine has been missed, and whether the older person coughs or chokes when eating. If anything unusual is found, deal with it early and do not wait until the follow-up appointment to raise it with the doctor.

Questions to ask in the ward before discharge

The ward is where information is most concentrated. Asking the questions below before discharge saves a lot of groping around after going home:

  • What is the older person’s mobility at discharge? How much worse is it than before admission?
  • Which medicines are new? Which old medicines should be stopped? What should be done if a wrong medicine is taken or a dose is missed?
  • When are the follow-up dates for each specialty? Which one is most important and must not be missed?
  • Which symptoms mean the older person must see a doctor at once, and not wait for the follow-up appointment?
  • Has a home assessment by a physiotherapist or occupational therapist been arranged before discharge, or a referral for such a service provided?
  • If long-term care services are being considered, who will start the referral process for the standardised assessment?
  • Do not wait until the day of discharge to look for aids and tidy the home. On the day of discharge, transporting the older person, collecting medicines and signing documents are already more than enough to do.

Linking up with community services after discharge

The hardest part of the transition after discharge is the handover of responsibility. The hospital’s responsibility ends the moment the patient is discharged, while community services such as day care centres, meal delivery and home care generally do not start on the same day, even once a referral has been made. The gap between the two is, in practice, filled entirely by the family. If the older person needs subsidised long-term care services, the standardised assessment must be passed first. For how the assessment and waiting list actually work, see standardised assessment and waiting lists for elderly services. If you plan to hire help at your own cost to share the load during the gap, the options and how the work is divided are covered in escort services and hiring care help.

Discharge is only the first checkpoint of a long care journey. For the other important parts, such as residential care homes, allowances and respite, the overview of caregiver resources offers a complete information guide, and family members can read through them one at a time according to what is most urgent now.

If the hospital says discharge is possible, must the patient be taken home at once?
There is usually a buffer of a few days, but not much. In public hospitals the treating doctor sets the discharge date according to the patient’s clinical condition, and with beds in short supply the timetable seldom waits for the family’s preparation. If the home environment or the help available is clearly not ready, the family should ask the ward nurse at once to arrange a meeting with the medical social worker. This is the only way for the family to formally say that they are “not ready”. The social worker can help assess whether a referral for transitional support is needed, but also cannot postpone the discharge time indefinitely.
How can a medical social worker help?
The medical social worker coordinates the discharge arrangements. This includes assessing the family’s ability to provide care, referring to community services (such as home modifications, meal delivery and day care centres), helping with applications for financial assistance, and starting the referral process for the Standardised Care Need Assessment Mechanism for Elderly Services when the older person needs long-term care. Medical social workers handle a large number of cases at the same time, so when family members meet them, asking specific questions (for example “who will help with bathing after going home?”) gets more practical follow-up than saying in general terms that they do not know how to cope.
What should we watch for in the medicines and follow-up arrangements received at discharge?
There are three main points. First, check the discharge medication list against the medicines taken before admission for duplicates or conflicts, because older people often end up “taking the old medicine and the new medicine together”. Second, look at the specialty and date on each follow-up slip to see whether they overlap. Third, ask which symptoms mean seeking medical help early, instead of leaving them until the follow-up appointment. These questions are much easier to get answered from the medical staff while still in the ward than by phoning after going home.
Why are the first two weeks after discharge so critical?
Because the gap in the older person’s abilities often only shows during this time. In hospital there are bed rails, nurses to help and flat floors. At home there are thresholds, stairs and slippery bathrooms, and most older people’s fitness has clearly declined after a hospital stay. The first one to two weeks after discharge are not only the peak period for falls. They also decide whether the older person is smoothly taken over by the family, or needs to be admitted again. The home environment and the help arranged for this period deserve to be prepared seriously as a separate item.

Practical details on discharge preparation

The next checkpoint

Disclaimer: This article is general health information and is not professional medical advice. If you have any health concerns, please consult a qualified healthcare professional.