Transition Planning for Elders

My recent post about the Negative Effects of Hospitalization explained some of the challenges for elders in general who are hospitalized, as well as how hospitalization can impact cognitive functioning and exacerbate Sundowning.

What if your loved one is currently in the hospital?  Where do you go from here?  How can you minimize the risks of transitions (from home to the hospital, returning home afterwards, or going to rehabilitation or a care facility)?

Transitions bring the potential for problems, because of potential inconsistency in care, miscommunication, and changes.  Patients with Sundowners need special care and attention during transitions to new environments.

  • Ensure an advocate is closely involved during all transition times.  Can a family member be present?  Should you consider a professional advocate/geriatric care manager to assist?  The advocate’s primary role is communication–providing good information so the medical providers can do the best job/have an understanding of the patient and ask vital questions.
  • Plan early to avoid surprises and feeling rushed.  Patients leave the hospital sicker than ever before.  As soon as your loved one is hospitalized, begin the dialogue about expected outcomes and what will happen next.
  • Make sure all parties have a thorough, realistic picture of your loved one’s situation and needs.  When your loved one goes to the hospital, inform staff of behavior challenges and concerns.  When you are planning for discharge, explain what resources the patient does or does not have and where you will need help for safety.  If your loved one is going to a care facility, inform staff of his/her needs and ask them to explain how their staff will provide the necessary care and precautions.
  • Keep good records and use a checklist to help manage the transition process.  You may want to read this article on care management checklists, where you can get a copy of a free discharge planning checklist.

It is best to minimize change for a person with Alzheimer’s or other forms of dementia, but that is not always possible.  You can, however, take steps to make transitions more smooth and ask those involved in your loved one’s care to partner with you in doing so.

Do you have a story to share about what happened during a transition for your loved one?  A tip you can offer to others? We welcome comments!

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