The doctor will make recommendations on discharge planning from the hospital setting that will best suit the patients' needs for returning to the community or home setting. There are several options the doctor may order depending on the patient's needs, goals and desires.
Home health could be one option. A home health agency could send a nurse, a nurse's aid and a therapist into the patient's home to continue the plan of care as ordered by the physician. Home health care agencies may go into the Personal Care Home and Assisted Living environments as well as a patient's private home.
Outpatient therapy could be another option. This is an environment in which a patient will travel to a therapy location and work with the therapists as outlined and ordered by their physician.
The most common option for the elderly is to discharge to a Short-Term Care Rehabilitation Center; this may often be referred to as a Post Acute Care Unit or TCU (transitional care unit). With this option, the patient has an interdisciplinary team available 24/7 which will include:
- Physician, this may be the patient's personal physician or a physician who attends to patients in a rehabilitation facility
- Licensed, skilled nurses (this could include a combination of LPN (licensed practical nurse/LVN (licensed vocational nurse) and RN (registered nurse) with guidance from a Director of Health Services to manage medical regimen as outlined and ordered by the physician
- Certified Nursing Assistant (CNA) to assist with activities of daily living
- Dietary staff including a Dietary Manager to manage meal preparation and dietary needs
- Social Services department including a Social Services Director to assist with psychosocial and emotional needs as well as advance directive planning and discharge planning
- Activities department including an Activities Director that will coordinate activities for the patients in the facility and specific needs of the patient admitted for the short term stay
- Therapy department including physical, occupational and speech therapist which will manage and perform the therapy techniques ordered for rehabilitation
- Customer Service Representative or Senior Care Partner. This staff member is a nurse who acts as patient advocate, facility representative, facilitator and liaison between the interdisciplinary staff and family.
- Admission coordinator to assist with the admission to the facility process and discuss payment options for services rendered while in the facility
- Financial director to assist with payments and options associated with payment and payor sources
- Housekeeping staff with Housekeeping Director to maintain cleanliness of the building and the patient's room
- Maintenance staff with a Maintenance Director to manage the mechanical operations of the building
- Administrator to oversee all operations and disciplines