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?
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.