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You are a hospital social worker and Mr. and Mrs. Calhoun, an older Caucasian couple, came to your attention after Mrs. Calhoun had been hospitalized for dehydration. Her primary care physician found her to be quite confused and delirious during her visit to the doctor's office, so she was sent to the hospital. Mrs. Calhoun had been stable for the past few days, but her age (73) and her confusion had flagged her as an at-risk patient who would need additional attention to develop a discharge plan. The Calhoun’s live in their own home, and their only son lives about 20 minutes away and helps out fairly regularly. The Calhoun's live modestly on their pension and social security. Mr. Calhoun indicated that he wanted his wife discharged to their home because he was quite capable of looking after her. Mr. Calhoun himself did not appear to have any observable limitations in his ability to carry out activities of daily living, although he did look tired. The Calhoun’s son stated he could only check in on the weekends. You are not entirely convinced of Mr. Calhoun's ability to adequately care for his wife—she did after all have to be hospitalized for dehydration. According to the patient's chart, Mrs. Calhoun's confusion still seemed to persist; although, she seemed okay when you spoke to her. The physician and the nursing staff want you to develop a discharge plan fairly quickly. What does your discharge plan include? Do you send Mrs. Calhoun home with in-home services? Do you send her for long-term care? Do you recommend follow up? What services (if any) do you support for Mr. Calhoun and their son?

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In discharge planning, it's important to identify potential caregivers who can assist the patient during the transition process. As a social worker, you understand that Mr. Calhoun wants his wife discharged to their home. However, you must also ensure that he understands all his duties as Mrs. Calhoun's caregiver.

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In discharge planning, it's important to identify potential caregivers who can assist the patient during the transition process. As a social worker, you understand that Mr. Calhoun wants his wife discharged to their home. However, you must also ensure that he understands all his duties as Mrs. Calhoun's caregiver.

To do that, you will want to engage Mr. Calhoun in the discharge planning process. Prior to the day of discharge, you may decide to have a discharge planning meeting with Mr. and Mrs. Calhoun and the couple's son. During the meeting, you will address concerns and questions about Mrs. Calhoun's transition home.

As for whether you should recommend in-home or long-term care for Mrs. Calhoun, that will depend upon her condition. Generally, patients are recommended for long-term care when they need 24-hour supervision due to a physical or mental condition. Long-term care, however, can be provided in a variety of settings: at home, in a nursing facility, assisted living community, or senior retirement home.

As Mrs. Calhoun has already been identified as an at-risk patient, it is important to include either a nurse or physician in the discharge planning meeting. During the meeting, the health care professional can address Mrs. Calhoun's specific medical needs. For example, does Mrs. Calhoun have a condition that requires crucial attention to proper hydration? At this point, you would also determine the level of care Mrs. Calhoun needs on a daily basis.

Here is a checklist to determine this:

1) Does the patient need assistance to bathe, dress, or eat?

2) Does the patient need help to go to the bathroom?

3) Does the patient need help with the housework? You may be able to determine how much Mr. Calhoun can do in this area to assist his wife. Also, information you gather during the meeting will help you determine if the son needs to step up in this area as well.

The attending physician or nurse will be able to answer questions about the patient's condition, which can help you determine what type of medical services Mrs. Calhoun will need as she transitions home. Since the Calhouns live modestly on their pension and Social Security benefits, they may have few personal savings. In this case, they must turn their attention to Medicare.

Be aware, however, that Medicare will only pay for "medically necessary services." Please refer to the Medicare link for a list of such services. Basically, "medically necessary services are defined as those that are needed to diagnose or treat a medical condition."

So, it is important to determine whether Mrs. Calhoun has skilled nursing needs that must be fulfilled by a trained medical professional. This is because Medicare will (for a limited time) cover custodial care (help with personal hygiene or self-care needs) if medically necessary services are also needed. Look for covered preventive services under the "exceptions to the medically necessary requirement" heading at the Medicare link. Also, this link may be useful: What does medically necessary mean in Medicare?

Another helpful link: Does Medicare cover long-term care?

In other words, Medicare will only pay for short-term in-home care (which may include custodial care) if they are ordered by the doctor. Such in-home care must include one or more of these to qualify for Medicare reimbursement: medication follow-up, assistance with rehabilitative exercises, regular vital status checks, wound care, diabetes management services, etc.

Medicare will also pay for short-term rehabilitation services at a facility, if it is ordered by the doctor. The doctor will order these services if the patient needs physical or occupational therapies during the transition process.

To recap, the discharge planning meeting should involve Mr. and Mrs. Calhoun (if possible), the Calhouns' son, and a trained medical professional (either a nurse or attending physician). After the meeting, you should be able to determine whether Mrs. Calhoun needs medical or custodial care, or both.

On the day of the discharge, you must ensure that Mrs. Calhoun's caregivers (in this case, it would be Mr. Calhoun and the couple's son) has the following:

1) A list of medications (doses, when to take them, and how to take them).

2) A date for a follow-up appointment.

3) The contact information for a trained medical professional (such as a physician) if problems arise during the transition process.

4) A list of support services for caregivers. Here is a link for federal programs that support in-home caregivers: the United States Administration for Community Living.

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