Accommodation, Part 2

Accommodation, Part 2

Original Air Date: February 22, 1998

What is discharge planning?

Discharge planning is the process of planning and organizing for discharge from hospital--where a person will go, what type of support or facilities they will need in order to leave hospital safely.
How does it work?
- Usually, when a person is admitted to hospital, within the first few days doctors will do an assessment. If they believe the person might not be able to return home upon release from hospital, they will contact a discharge planner at the hospital.
  
  What are the "alarm bells" that tell doctors a patient can't go home again?
  - cognitive impairment
  - continuing medical condition
  - living alone
  - multiple admissions to hospital
  - limited family or community supports
    What's the process that begins when a doctor decides Mom is ready for discharge from hospital but can't go home?
    - Nobody's ever prepared for this, and they're never happy with the news. As a result, there's a degree of distress that has to be dealt with even before the placement issue can be addressed.
    - This is particularly problematic in cases where the patient has become ill very suddenly, as opposed to deteriorating over time (i.e. when a stroke happens, the patient and family have to "get their heads around" the reality of the stroke before they can begin to move on to the placement issue).
    - The discharge planner will talk to the family about what options are available based on Mom's condition and abilities.
    - The patient and family, assisted by the discharge planner, then begin the application process.
      What's involved in the application process?
      - The application form itself will include such things as demographic information, a medical assessment, a functional assessment (disruptive behaviour, ability to dress or bathe oneself), and a social assessment (interests, family involvement, financial information).
      - The patient has to select their preferred locations (in Ontario, usually five choices) from among all the facilities in their province of residence, and must be willing to take whichever one of those comes up first.
      - In some facilities, the pressure to free-up beds means patients are forced to choose only from a list of facilities that have a quicker turnover rate. (This is where the practice becomes controversial: what do these processes do to the patient's control over decision-making in matters that have a huge impact on their lives?)
      - When a spot becomes available in one of the chosen facilities, the patient has to decide virtually immediately (i.e. within 24 hours) whether they'll accept the spot.
      - If a patient in hospital refuses the first available spot, the hospital can institute a co-pay charge equivalent to the cost of a long-term care facility. This charge will continue until the patient leaves the hospital. (People who are awaiting placements from home are not penalized in any way for refusal. They are able to wait for another vacancy if they wish.)
      - The difficulty in allowing co-paying patients to remain in acute care beds is that often there are acutely ill people waiting for those beds.
        
        How long is the wait?
        
        On average, it can be several months. (Preference is not usually given to individuals entering facilities from hospital over those who have applied from their own homes.)
        In extenuating circumstances, emergency admissions to long-term care facilities can be arranged. For example, an elderly wife may be the sole caregiver for her husband, who has severe Alzheimer's. If she is hospitalized with a stroke and he has no one to care for him, he can be admitted to a facility during her incapacitation.
        
        What is the role of the discharge planner during the waiting period?
        
        Have occasional meetings with the family to remind them of their choices so they're fresh in everyone's mind when one of them comes up.
        Remind the family that when one of their choices does come up, it'll happen with no notice, and they'll have to act immediately.
        Let them know where their family member is on the various waiting lists (in Ontario, there is a centralized database for this, but it's different across the country).
        
        Assuming the elderly person is able to make decisions in this regard, how important is it that they feel a part of the process?
        
        It's very important that the elderly person be involved in all aspects of planning. Their involvement should be limited only by cognitive ability.
        The greater the degree of input and control, the better the adjustment to the facility will be. (Studies show there is even a difference in mortality rates in this regard.)
        
        What kind of family issues arise in these situations?
        
        The emotional issues associated with these decisions is under-emphasized. It's an incredibly emotional time.
        "Old family stuff" will rise to the surface when emotions are bared. It's not uncommon to hear complaints from one sibling that he/she is bearing the entire burden and responsibility, or "Mom always liked you best, so it's your job."
        There can be huge problems when there's not one designated decision-maker who has the final say when families can't reach agreement.
        There is also potential for disagreement between the patient (parent) and an adult child over whether the parent can in fact return home. (If Mom is capable of decision-making, she has the right to decide whether or not to go to a facility.)
        
        What can families of seniors do in terms of advance planning in this regard?
        
        Don't wait until the senior has become ill or had an accident. The time to consider long-term care is when the person is still in good shape and able to travel around to explore and compare various facilities.
        If a senior is in a position where it's obvious they will likely need care down the road, the application can be made at any time. You don't have to wait until the decline has happened. Advance planning in this situation means the individual is moving up the waiting list while he/she's in relatively good shape and still in his/her own home.
        Not all seniors will agree to this, of course, but if it's explained to them that it will make things easier on everyone if their wishes and preferences in this regard are known in advance of an unfortunate event or illness, some will agree.
        
        What makes a successful placement?
        
        Giving the individual choice.
        Giving the individual control, where possible, over what's happening to him/her.
        Having family members that are supportive of the individual.
        Sufficient preparation: ensuring the senior understands the reasons for the placement; if possible, visiting the facility in advance of the permanent move.
        Degree of orientation given to the individual once they've arrived.
        
        What's the responsibility of the long-term care facility?
        
        The facility staff must recognize the significance of the decision to the individual.
        Support and orientation when the person arrives are crucial.
        The facility should encourage family members and friends to visit.
        
        What's the biggest challenge for discharge planners?
        
        Juggling the pressure from both sides: the need to free-up hospital beds vs. the shortage of beds in long-term care facilities.
        
        Are people being discharged too soon?
        
        There is some evidence to suggest that people are being discharged "quicker and sicker"--perhaps under the pressure of the individuals filling up emergency wards.
        However, there are now more supports in place for home care and community supports to pick up where hospital care leaves off.
        
        What kind of follow-up is done by the hospital discharge planner?
        
        Probably none. Hospitals just don't have the resources available to follow-up on every case.
        Former patients and their families are always free to call if they need anything, but it's up to them to do so.

What does Concerned Friends do?

First, the group advocates for good, quality care in long-term care facilities by providing residents and their families with information to help them advocate for themselves.
The second role is a consultancy-type role. People will call the group when they are initially faced with having to find a facility for a family member.

What's the difference between a nursing home and a home for the aged?
- They're essentially the same thing: both are government-funded, both must meet the same set of regulations.
- They are residences that provide personal and medical care for elderly individuals who are frail or ill.
- The health care is paid for by the province.
- The term "nursing home" can also be used to describe private facilities of this type.
  
  What's a chronic care hospital?
  - It's a wing of a hospital, or an entire hospital, that's dedicated to providing ongoing care to patients with chronic illnesses or conditions. In Ontario, they fall under the Hospitals Act.
    
    What's a retirement home?
    - Retirement homes are not regulated in any way. Virtually anyone can hang out a shingle and say they're running a retirement home.
    - They aren't really meant for frail or ill residents, and you pay for whatever services you need (i.e. nursing).
    - They are a "buyer beware" service.
      
      How do you recognize a good facility?
      - A good facility is one where you feel the staff are warm and caring. The attitude of the staff can make up for a lot of other things that may be lacking in other areas.
      - When visiting the home, be very observant: talk to as many staff members as you can, and go on more than one occasion to get a better idea of what goes on in the facility.
      - Other than other obvious things like cleanliness, no pervasive unpleasant smells and good food, a lot of what you should look for depends on what's important to the individual: things like size of the room; whether there are gardens or a yard; proximity to family members.
        
        What's the general state of long-term care facilities in Canada?
        
        Things are improving. There has been progress in that there aren't as many complaints as there once were.
        As well, there aren't as many facilities "under enforcement"--the process whereby regulators keep a watchful eye on a facility that's had a lot of infractions to monitor compliance with standards and regulations.
        
        What's the "big picture" problem?
        
        Lack of available beds and long waiting lists.
        The best homes have waiting lists of three to four years, so people end up having to take whatever bed is available, leaving them frustrated and unhappy.
        
        Are people being released from hospitals before they're ready?
        
        It's possible that they're being released in many cases before they're ready emotionally.
        Overall, long-term care facilities are taking on heavier and heavier care cases.
        
        What future trends will we see in long-term care facilities?
        
        Concerned Friends has developed a pilot project to be implemented in the next few months whereby all nursing and retirement homes will have a "residents' council" for family and staff to work together to improve the facility.
        It will allow them to have dialogue on any problems or concerns before the issues become too problematic or too large to be dealt with within the facility.
        Additionally, the residents' councils will allow residents' family members to become acquainted with other families and provide mutual support so they don't feel isolated.
        
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