Discharge planning

Planning for leaving the hospital

Making plans for when you leave the hospital is a very important part of your recovery. Your health care team will work with you and your care circle to help develop your discharge plan. By using this plan, you and your care circle can make most arrangements for leaving the hospital before your surgery.

A discharge plan is one of the following:

Home

You can return to your home if you can do the following at the time of discharge:

• You can get in and out of bed and a chair with little help.
• You can walk with your walker, crutches or cane.
• You can walk the distance from your bedroom to your bathroom and kitchen.
• You can go up and down stairs safely if needed.

You also need to have help from your care circle on a regular basis until you regain your independence and self-confidence in walking and daily living activities. You may only need someone to be available to check on you or you may need someone to help you with all of your daily activities.

Home with home care

Some people can return home at discharge but need some help beyond what their care circle can provide. Your health care team will help to determine what your home care needs are.

While you are in the hospital, a social worker will talk with you to see if you qualify for visits from home health providers.

These home health providers can be physical or occupational therapists, home health aides or nurses who come into your home to help you with walking, strengthening exercises, daily living tasks and safety issues, and to monitor your medical condition.

Transitional care unit (TCU) or short-term rehabilitation center

Many people can return home at discharge but there are some who need more help and services than can be reasonably provided at home. Such services can include daily skilled nursing care, additional rehabilitative therapy or both.

If you need more help and services than can reasonably be provided at home, you may qualify for a stay at a transitional care unit (TCU) or short-term rehabilitation center. Your health care team will work with you to make sure your plan for leaving the hospital (discharge plan) is safe.

In a TCU or short-term rehabilitation center, you can continue your rehabilitation program and have your medical needs monitored until you can safely return home. Therapy sessions focus on building strength, endurance and self-care skills. You will be cared for by a team of health care providers who will work with you and your care circle so you can return home as soon as possible.