Vase of roses in hospital window

Navigating Hospitalizations 101: The Hospital Care Team

11/1/16 by Sarah Lahr

The moment you dread…Mom is headed to the hospital for the first time since you have had to step in to do more for her. You are now faced with navigating one of our nation’s most complex systems: hospitals. You find yourself getting frustrated because you can’t take time off from work to catch all of the doctors. Your lunch breaks are taken up by returning messages from the social worker. You want to be proactive with planning ahead, but find it challenging to get information on what Mom’s needs are going to be when she leaves the hospital. Then you find out only a few hours in advance that she is being discharged, needs placement in a Transitional Care Unit (TCU), and you still need to find a facility – today.

This experience is stressful and unfortunately not uncommon. However, there are things that you, the family caregiver, can do to be prepared for the hospital discharge. In this post, you will find tips for working with your family member’s care team. In a second post, you will find a guide to transitional care unit stays.

Who Makes Up the Hospital Care Team?

The hospital care team is made up of: physicians, specialists, physical and occupational therapists, social workers, nurse care coordinators, and the palliative care team (if they are involved). This team reviews all patients each day to follow the clinical progression of care to help families prepare for the discharge process. This team obtains information on the patient’s living situation at home to make the most appropriate recommendations.

Information the Care Team Needs

  • How does the patient get around their home? Do they use a walker or wheelchair? Are there stairs to get into the home? 
  • Are they able to dress, bathe, toilet, manage medications, cook meals, drive on their own? If not, who assists them with these things?
  • Do you have concerns about how the patient has been managing at home?
  • Does the patient have a case manager through the county or managed care plan?
  • How are YOU doing while assisting the person you care for at home? Are you struggling and burning out, needing support?

It may be good to have this information written down and give it to the nurse to pass on to the care team.

Communicating with the Care Team

  • Sometimes, it can be challenging to get the recommendations of the care team. Most of the discharge recommendations come from physical therapy. Ask the physical therapist what they would recommend from a functional perspective. If the doctor is meeting with you, ask him or her about the discharge recommendations.
  • Social workers are involved with setting up services and logistics, such as transitional care (TCU) placement, homecare services, and transportation for discharge. Their primary focus is on discharges that happen that day. Depending on how busy the unit is, they may get to you ahead of time, but that doesn’t always happen.
  • Don’t worry! Even if the social worker can’t get to you until the day of discharge, you still have the power to make discharge day a smooth transition by being prepared with transitional care choices.
  • Ask for a Transition Conference: This is a conference with the care team to discuss the medical plan, goals, services needed at discharge, and when discharge is anticipated. You will also be given the opportunity to ask questions of the care team. Asking questions is a good way to help make sure the entire care team, including you and the person you care for, are in agreement with the discharge plan. Sometimes, a Transition Conference will be suggested by the care team; however, they don’t automatically do them for everybody. If this is something you want, ask the nurse to pass it on to the care team.

You Are Member of the Team

Although the hospital care team does their best to be as proactive as possible, you may not be able to meet with staff when it’s convenient. Know that information you provide as the family caregiver is crucial to create the most solid discharge plan possible. Now you, the family caregiver, have the information and tools to be a key element of the care team

Sarah Lahr spent the summer 2016 working full-time as a medical hospital social worker. She previously worked in the Wilder Foundation’s Caregiver Services Program as the care coordinator. She is starting graduate school this fall in the Masters of Public Health Administration & Policy program at the University of Minnesota to study the integration of the healthcare system and home & community-based services to support older adults and their caregivers in their communities.

Photo: Roses in hospital room | Charles Stanford | CC BY-SA 2.0