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TOWNSEND — Planning to leave the hospital begins as soon as a patient is admitted for treatment, Patricia Connelly said.

Hospitals are sending people home quicker and sicker than ever before and patients need to know what is going to happen next, the community service representative for Home Instead Senior Care told people at the Townsend Senior Center on June 4.

“Discharge planning is a very complex subject,” she said.

It is a process used to decide what a patient needs to make a smooth transition from one level of care to another. A patient could be leaving the hospital to go into another treatment center or returning home.

The discharge plan is put together by a team of people that can include the patient, the caregiver, the health-care proxy and medical personnel such as nurses, case workers and therapists.

Patient preparedness can make a difference in what the plan contains.

It is critical to have a health-care proxy, a person legally designated to make medical decisions for a patient, before going into the hospital, Connelly said.

“A health-care proxy trumps everything when you go into the hospital,” she said.

The discharge plan covers many things. It should compare the condition of the patient before admission, at release and give an idea of how the condition may continue to change.

If further care is needed, either in a different facility or at home, the discharge plan might include placement or a referral to an agency.

If the client is not happy with the suggestions, he can ask for a change, said Candi Millard, another community service representative.

“The patient should be able to chose the visiting nurse they want,” she said, “Knowledge is power.”

Case managers will often suggest agencies they have worked with before. Sometimes the patient may have to reach out to others to help find a placement with an agency they know or in a facility closer to home, Millard said.

“Do not expect for them (discharge planners) to do research on the next facility,” Connelly said.

“Do your own due diligence,” she said.

If the patient is returning home and needs help from a caregiver, the plan should include how the caregiver will be trained to provide any special services that are required, Connelly said, “This is huge.”

The plan should also include a medication review. Sometimes medications that are prescribed during a hospital stay can interact with the patient’s other medications.

If durable medical equipment like a wheelchair is needed, the plan should include where it is coming from and who will pay for it.

A patient may require assistance with meals, household tasks and transportation. The discharge plan should address these issues.

Sometimes the hospital may provide a patient advocate to assist patients in talking with health-care providers.

“We don’t know how to speak with them,” Connelly said.

Sometimes patients must be their own advocates or have a health-care proxy to step up for them.

If the patient feels unready to leave the hospital, the plan can be reviewed within 24 hours while the patient remains in the hospital.

If a review finds the patient should stay, care will continue. If the review finds the patient did not need the extra time, the patient is responsible for the hospital charges.

Patients returning home should contact their Council on Aging and local police department to say they are back and might need some help.

“That helps them do their job well,” Connelly said.

“That’s one of the advantages of living in a small town,” Millard said, “You know them.”

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