Hospitalization and discharge planning

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1 Hspitalizatin and discharge planning A planned hspitalizatin r unexpected health emergency can ccur at any pint during the disease prgressin and may r may nt be the result f Alzheimer s r anther dementia. A hspital visit r vernight stay can cause anxiety and discmfrt fr the persn with the disease. The change frm hme t an unfamiliar envirnment and the added stress caused by medical interventins may lead t increased cnfusin r disrientatin. Knwing what t expect during a hspital visit can help make the experience mre cmfrtable fr everyne. Plan ahead In the early stage f the disease, the persn with dementia is able t make decisins n his r her wn behalf and shuld be included in all cnversatins abut medical care. It is imprtant t address wishes fr health care, including emergency medical treatment, as early as pssible s that family and care team members can cnfidently implement the plan in the event the persn is n lnger able. As the disease prgresses, it will becme increasingly difficult fr the persn with dementia t understand the purpse f hspital visits and medical interventin, and he r she will be unable t participate in the health care planning prcess. The care partner r a member f the care team shuld always be present t explain, as much as pssible, the reasn fr the hspital visit r medical interventin; prvide supprt; and act as an advcate n the persn s behalf. Cnsider the fllwing: Prepare an emergency kit with legal paperwrk and current medical infrmatin. This infrmatin shuld be available in an easily accessible place, such as in an envelpe attached t the refrigeratr. Sme items t include: A list f current medicatins and allergies. Cpies f legal papers (e.g., living will, advance directives, pwer f attrney, d nt resuscitate (DNR)). Insurance infrmatin. Name and phne number f physician. Names and phne numbers f the emergency cntact and additinal care team members. Request fr brain autpsy r rgan dnatin. Review current legal dcuments stating preferences fr health care, including life-sustaining treatment. The fllwing dcuments help prvide assurance that the wishes f the persn with the disease are upheld: Pwer f attrney fr health care: Names a health care agent t make health care decisins n behalf f the persn with dementia when he r she is unable. Living will: A type f advance directive that includes preferences fr medical treatment, including life-prlnging treatments. Medical release f infrmatin: Ensures that a dctr can share infrmatin with a family member r friend f the persn with the disease. This can be beneficial t thse wh are helping t crdinate care.

2 Hspital visitatin frm: Hspitals in sme states may enfrce strict visitatin laws and/r require special frms if a relatinship, such as a dmestic partnership, is nt legally recgnized in that state. D nt resuscitate (DNR): A physician rder t prevent attempts at revival, particularly CPR r defibrillatin. Withut it, medical prfessinals are required t perfrm resuscitatin. Prir t hspitalizatin Share infrmatin regarding the diagnsis, ther medical cnditins r allergies with the entire medical team. Prvide infrmatin abut persnal habits, dietary preferences r any envirnmental needs, like a private rm, that wuld make the experience mre cmfrtable. Ask questins Which prcedures will be perfrmed and hw? What are the risks and benefits? What are the expected results? What is the expected length f recvery? Is assessment r treatment available at an utpatient clinic? Hw lng is hspitalizatin required? If anesthesia is used, hw will this affect cgnitin? What are the visiting hurs? Are extended hurs available? During hspitalizatin Sme f the mst cmmn cncerns during hspitalizatin include cmmunicatin, safety and nutritin. The fllwing suggestins may help facilitate a safe and cmfrtable experience: Cmmunicatin Make sure that all treating physicians and medical prfessinals are aware f the diagnsis f Alzheimer s r ther dementia. If the persn with dementia has difficulty cmmunicating, ffer suggestins t medical staff abut what the persn may want r need. Be present when a test r medicatin is administered t ffer supprt r t answer questins frm the medical team. Cnsult with members f yur care team. Wh is able t stay during preadmissin testing? Medical prcedures? Hw ften will smene be able t visit during the hspital stay? Safety Cnfirm that imprtant infrmatin, including dementia diagnsis and any behaviral cncerns r allergies, is nted n the medical chart. Infrm medical staff if there is a histry f wandering r getting lst. Bring familiar items frm hme t make the rm feel mre secure and cmfrtable fr the persn with the disease. Behavirs Alert the medical staff f any triggers that may cause unpredictable thinking r behavirs. Offer suggestins n appraches that may help reduce these behavirs.

3 Infrm medical staff f a histry f behaviral reactins t certain medicatins. Discuss limiting the number f visitrs if the number f guests r medical staff visiting the rm becmes t stressful. Nutritin Share any dietary preferences with medical staff. Arrange t be present during meal times if the persn has difficulty feeding him r herself, r alert hspital staff t this need. Offer suggestins t encurage gd nutritin and hydratin. Ntify medical staff f any difficulties chewing r swallwing. Medicare rights A hspital must share a cpy f the Imprtant Message frm Medicare abut Yur Rights (smetimes called the Imprtant Message frm Medicare r the IM) t all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrllees) within tw days f admittance and prir t discharge. If yu dn t receive this ntice, ask fr it. This frm indicates that: The patient has the right t receive all f the hspital care necessary fr the prper diagnsis and treatment f the illness r injury cvered by Medicare, Medicare Advantage r ther Medicare managed care plan (if the patient is a plan enrllee). The patient has the right t knw abut any decisin that the hspital, his r her dctr, Medicare health plan, r anyne else makes in regard t the hspital stay and wh will pay fr it. The patient s dctr, Medicare health plan r the hspital shuld arrange fr the services needed after leaving the hspital. The patient has a right t knw abut these services, wh pays fr them and where he r she can get them. The patient is infrmed f their right t file cmplaints and appeal a discharge decisin. They are prvided with the name f the Beneficiary and Family Centered Care Quality Imprvement Organizatin (BFCC-QIO) in their area. The BFCC-QIO is an utside reviewer hired by Medicare t review cmplaints and discharge appeals. Hspital discharge planning At the end f a hspital stay, health care prviders will make recmmendatins fr lng-term care needs and recvery fllwing hspitalizatin. A member f scial services r a discharge planner may als be invlved if the care plan calls fr in-hme services, referrals t rehabilitatin facilities, r utpatient services. Pst-peratinal r discharge rders may invlve several cmpnents, including new medicatin, therapy, wund care r mnitring. The fllwing questins may help the individual and their care team t prepare fr discharge: Which activities may require assistance after discharge? When is it safe t engage in physical activity? What is the safest way t manage pain? Have medicatins changed and hw ften shuld they be administered? Which signs r symptms are causes fr cncern? Wh shuld be cntacted if these ccur? Is a fllw-up visit necessary? If s, when will it ccur?

4 Discharge hme If the persn with dementia is able t return hme, the discharge planner will assess the persnal and cmmunity supprt available. If the persn r members f their care team have cncerns abut the feasibility f prviding care at hme, this shuld be discussed with the discharge planner. When planning fr in-hme discharge, a persn with dementia and his r her care team may cnsider these questins: Are there family and friends available t help? What type f care is needed? Which activities can the persn safely manage withut assistance? Which cmmunity service agencies are available t assist? What services d they prvide? Hw will the cst f in-hme services be cvered? Discharge t a residential care r rehabilitatin facility If the persn with dementia is nt able t return hme and needs services frm a residential care r rehabilitatin facility, the discharge planner shuld identify lcal facilities with vacancies and prvide the family and individual with infrmatin t help make the selectin. Typically, it is the respnsibility f the family t cntact the facility with any questins and make the final selectin abut placement. The discharge planner will fllw up with the chsen facility t share medical infrmatin and discuss discharge status. If there are n vacancies available at selected facilities, discharge planners are required t ffer additinal ptins. A hspital cannt frce an individual t enrll in a facility that des nt meet his r her needs; is nt Medicare/Medicaid certified; r is at t great a distance frm family. A patient cannt be frced t be discharged withut cnsent frm a legal representative. When planning fr discharge t a residential facility, a persn with dementia and his r her care team may cnsider these questins: Des the facility have services designed specifically fr individuals with Alzheimer s r dementia? What is the recmmended length f stay? When will re-evaluatin ccur? What types f services and treatments will be cnducted? Hw will the cst f treatment be cvered? Hw are facilities evaluated in terms f safety, cleanliness and staffing? Steps t appeal a discharge 1. Yu must cntact the BFCC-QIO n later than yur planned discharge date and befre yu leave the hspital. If yu d this, yu will nt have t pay fr the services yu receive during the appeal (except fr cinsurance and deductibles). Yu can file a request any day f the week. Once yu speak t smene r leave a message, yur appeal has begun. Ask the hspital fr help if yu need help cntacting the BFCC- QIO. 2. Yu will receive a detailed ntice frm the hspital, yur Medicare Advantage r ther Medicare managed care plan (if yu belng t ne) that explains the reasns they think yu are ready t be discharged.

5 3. The BFCC-QIO will ask fr yur pinin. Yu r yur representative need t be available t speak with the BFCC-QIO if requested. Yu r yur representative can chse t give the BFCC-QIO a written statement, but yu are nt required t d s. 4. The BFCC-QIO will review yur medical recrds and ther imprtant infrmatin abut yur case. 5. The BFCC-QIO will ntify yu f their decisin within ne day after it receives all necessary infrmatin. a. If the BFCC-QIO finds yu are nt ready t be discharged, Medicare will cntinue t cver yur hspital expenses. b. If the BFCC-QIO finds yu are ready t be discharged, Medicare will cntinue t cver yur services until nn f the day after the BFCC-QIO ntifies yu f its decisin. 6. If yu miss the deadline t appeal, yu have ther appeal rights. Yu can still ask the BFCC-QIO r yur plan (if yu have ne) fr a review f yur case: a. If yu have Original Medicare: Call the BFCC-QIO listed in yur IM. b. If yu belng t a Medicare Advantage Plan r ther Medicare managed care plan: Call yur plan. 7. If yu d nt appeal, r the BFCC-QIO finds yu are ready t be discharged, but yu decide t stay in the hspital past yur planned discharge date, yu may have t pay fr any services yu receive after that date. TS-0004 Updated Octber 2016

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