Are you or a loved one currently in a nursing facility? Are you considering a return to a community-based setting?
Planning an effective transition back to the
community requires the collaboration of a number
of people, including the consumer, the facility
staff, and family. This guide is designed to
highlight some important considerations before
transitioning back home. If you have additional
questions about discharge options, please
consider our free Options Counseling program.
On occasion, nursing facility staff may have different comfort levels with risk than the client or caregiver. If a nursing facility is recommending against discharge because of “risk”, make sure that you understand the exact nature of the nursing facility’s concerns. You may or may not agree with them! You can also contact Boston ElderINFO at 617-292-6211 to determine if the person in question is eligible for any home-based services which may help alleviate discharge risk.
Any resident of a long term care facility has certain rights, including the right to select your own personal physician, the right to refuse treatment, and the right to obtain copies of your medical record. For a full listing of resident rights, developed by the Commonwealth of Massachusetts,
If you are concerned that you or a loved one’s rights as a resident of a long term care facility are not being respected, call your local Massachusetts Long Term Care Ombudsman. You can learn more about the program here.
What are the client’s goals?
Does the client want to go home? Are they more comfortable in a nursing facility?
What are the client’s expectations in the short
and long term?
Does the client have realistic expectations about what a safe and effective discharge will require, and what life in the community will be like?
What are the expectations and goals of the
Are the informal supports (such as caregivers) aware that a community-based discharge is an option? Do they have realistic expectations about what a safe and effective discharge will require?
How much informal support can the client expect,
Are existing informal supports prepared to increase their level of commitment, if necessary? If not, what formal services are necessary to fill in the gap?
What are the expectations of the nursing
Has the nursing facility considered a community-based discharge? What, if any, concerns do they have? Can these concerns be addressed by a mixture of informal and formal supports?
These questions are designed to obtain a more nuanced understanding of the expectations around the transition home.
Do you feel comfortable that you and/or your
family understand your physician’s expectations
about your health status and decision to be
cared for at home?
If we are involved in your care, does the family want BSHC’s support in speaking to the facility social worker/medical staff?
Do you and you family feel that your current medical and mental health status is stable enough to be discharged to home care?
Do you have services and informal supports set up to meet all of your needs at home, and/or are you willing to accept such assistance?
Do you have a means of regularly obtaining your prescriptions and traveling to your doctor’s appointments? If you are relying on a friend or family member, what happens if they are unavailable?
Are you and/or your family comfortable that you and/or they can make important decisions about your health care needs? Do you and/or your family feel it is necessary to consult a professional about your decision making status?
Boston Senior Home Care strongly recommends the use of health care proxies for all individuals. It is also important to recognize that Massachusetts does not officially recognize living wills as legal documents. Click here to learn more about the differences between health care proxies and living wills.
What happens if you fall and injure yourself at home, or become ill? What is the emergency plan?
Does the client and/or family have reasonable expectations for ensuring the client’s safety? If the nursing facility has any specific concerns regarding home safety, has the client and/or family taken these concerns into account?
The following questions address any risk the client may pose to him or herself and allows the family and the consumer to begin thinking through potential solutions.
Are there any limitations that affect the client’s right to choose his or her own care?
Is there a guardian or other proxy relationship in place? Are there cognitive issues that affect decision-making capacity?
What constitutes “non-compliance” by the client living at home, and how would that non-compliance be communicated to the family, BSHC, or other health care provider?
Can we establish an “early waning” system to help alert care providers if the client begins to veer into unsafe territory? Are there certain signs or behavioral problems that providers and caregivers should be watching out for?
Is there a history of non-compliance or other risky behavior?
Has the client’s non-compliance or risky behavior caused previous hospitalizations, threatened their living situation, or otherwise negatively impacted their life in a serious way?
How serious is the risk?
Is the client’s life threatened? Is the risk immediate or long-term? How much more severe is the risk at home versus in the nursing facility?
Are others (caregivers, relatives, etc.) at risk or threatened by non-compliance?
Is the client responsible for anyone, such as a spouse or child? Are workers or caregivers at risk when in the client’s home?
Is the back-up plan realistic?
Does the client and/or caregiver have reasonable expectations for managing the risk? Is the client willing to comply with back-up plan procedures, up to, and including, readmission to a hospital or nursing facility?
What is the plan if the client’s non-compliance puts the client or others at immediate risk?
Is the caregiver willing to ask for increased assistance or intervention? Are providers aware of emergency procedures and signals?
A crucial piece of a safe transition home is the ability to appropriately manage medications, especially if the medications have been changed during the course of the client’s stay in the facility. Problems with medication management are a major cause of hospital re-admissions, which can lead to nursing facility re-admission.
Why is each medication prescribed?
Clients and caregivers should have a thorough understanding of each medication in order to increase compliance.
How often does each medication need to be taken? Can the medication be taken at the same time of day as your other prescriptions? How long will the medication have to be taken?
Will the client need help taking the medication? Will the client or caregiver have to set up a complicated schedule for taking the medications, and will this affect service delivery schedules? Does the consumer or caregiver have a plan for making sure the medication is refilled in a timely manner?
Should the medication be taken with food? Should the client avoid any particular types of food or beverages while taking the medication?
Should the client avoid alcohol or other foods? Will the current medication schedule allow the consumer to eat at reasonable hours and intervals – and if not, can the medication schedule be adjusted?
How will the client or caregiver know if the medication is effective?
Will the consumer need to be tested regularly? Are there certain symptoms that the client/caregiver should watch for?
Will any of the medications that the client is taking interact with each other?
Be sure that the prescribing doctor or pharmacist is aware of all other medications the client might be taking, including non-prescription or herbal supplements that the consumer may start using at home.
What possible side-effects or problems might the client experience? At what point should the client tell a doctor or health care professional about these problems?
Is there a possibility of vision impairment, dizziness, or other effect that may increase risk of falling?
Will the insurance program pay for the medicine? Is there a less expensive alternative?
Clients may not want to re-fill prescriptions that are extremely expensive. If there is not a less expensive alternative, clients and caregivers need to understand the importance of the medicine to agree to re-fill it.
These are some of the questions that may help a consumer understand the process of transitioning back home. For more information or to talk to a specialist, call Boston ElderINFO at 617-292-6211.