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Creating a Plan of Care Beyond Hospital Discharge Instructions

Caregivers creating a plan of care for their senior loved one.
There may be many additional tasks that are not covered in your loved one's hospital discharge plan. How will care be provided for those activities that are not covered in the discharge instructions?

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Ann was thrilled to learn her husband would soon be released after a week in the hospital following surgery to repair a knee injury. With her busy schedule working part time and caring for her grandchildren, though, Ann was starting to feel overwhelmed. "I need a plan," she told her friend Marge.

Ann was experiencing the anxiety that many likely face when helping a loved one transition home.

There may be many additional tasks that are not covered in your loved one's hospital discharge plan. How will care be provided for those activities that are not covered in the discharge instructions? Will someone need to be at home with your loved one throughout the day or just at specific times during the day?
Always ask medical professionals for a care plan along with the discharge plan. This care plan worksheet (PDF 258k) could help you prepare.

Outlined below are four key activity areas that may require family caregivers to assume more responsibility, time and effort than normal day-to-day activities. Many of these activities may also require assistance from trained professionals, including home health care aides. You should ask a loved one's medical professionals which ones will likely need to be addressed and work with your senior to make sure all important paperwork is in order.

Care Tasks

  • Change dressings
  • Monitor vital signs
  • Operate or adjust medical equipment
  • Assist with personal hygiene
  • Arrange for follow-up care
  • Maintain a schedule of health care visits and appointments

Medication Management

  • Order and pick up prescriptions and refills
  • Understand all medication labels, instructions and expiration dates
  • Administer the correct medication at the right time
  • Monitor for side effects
  • Store medications properly and safely
  • Maintain medication schedule
  • Dispose of medications
  • Use a medication tracking worksheet (PDF 600k) to record all medications

Household Management

  • Conduct safety checks
  • Prepare special meals such as liquid-only diets
  • Take additional shopping trips for special foods and supplies
  • Greet and supervise visiting health care and home care professionals
  • Arrange for deliveries of medical supplies and equipment

Family Communications

  • Prepare and maintain emergency and medical contact lists (PDF 725k)
  • Communicate frequently with family members
  • Pay medical and other bills
  • Provide instructions and training to other family members and friends
  • Assemble and store important documents like those listed below in a senior emergency kit
  • Help with legal and business documents such as Advance Directive, Living Will and Standard Will, Health Care/Financial Power of Attorney, Insurance and Financial Documents

The plan of care should go hand-in-hand with the discharge plan. Family caregivers may find that their loved one will benefit from hiring an in-home senior care agency to help carry out that plan. If you're working with an in-home care agency, be sure to discuss the above considerations with them as well. They'll be able to assist in making sure your loved one's care plan is complete and appropriately carried out.

The more information family caregivers can obtain on the current health care needs of their senior loved one, the easier it will be for them to develop, communicate and share a plan of care. There are many different caregiver situations that might arise, so having a plan of care will go a long way to help ensure that family members are well prepared for any situation.

Download the Returning Home guide.

Download the Canadian Edition of the Returning Home: Transitional Care Guide

Last revised: April 20, 2012

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Thoughts and stories from others
  1. October 14, 2020 at 4:11 am | Posted by Dorinda Bollettino

    It's hard to say


  2. June 21, 2016 at 12:22 pm | Posted by Nightingalepupil

    I work for a home health agency and the director didn't like the way I charted so now she is having me sign off on all of the plans of care prior to submitting it to the doctor for signature. I have no idea what should be included or what is necessary for the plan of care. Is this something I should be doing or is particular training or education required in order to sign it off prior to physician signature?


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