An overview of the issues and challenges when being discharge from a skilled nursing facility or other acute setting to home.

1. Discharge Planning Seminar

2. Home Sweet Home
• A plan is necessary to safely
transition home
• Start early
• Put time and thought into it
• Locate and utilize all resources
that will support your plan.
• Be realistic with your
expectations and limitations
• Think about possible changes
to your lifestyle

3. Hospital
Skilled Nursing | Rehab Facility
Transition Home
Home Health & Home Care

4. • Hospital
• Planned or Unplanned
• Fall, stroke, heart attack, respiratory issues, dehydration, malnutrition
• Stabilize to discharge to home or skilled nursing
• “Stabilize” does not mean health has returned to pre-hospitalization levels
• Skilled Nursing Facility
• 24 hour care, physician oversight
• Physical, occupational, and speech therapies
• Medicare determines length of stay based on progress
• Transition Home
• Who is happy going home?
• What do you miss most about home?
• What are some concerns in transitioning from a medical setting to home?
• Now consider
• What is your end goal? Is it realistic?
• How do you plan to get there?

6. “Going to the hospital is a traumatic
experience for anyone, however, returning
to the hospital is even more traumatic.”

7. Food for Thought
• Top 5 Reasons for Hospitalizations
for Older Adults
• Falls, injuries/accidents
• Symptoms related to heart disease
• Adverse effects of and
complications of medical treatments
• Abdominal pain (Dehydration and
Malnutrition)
• Infections

9. Know Your Resources
• Home Health
• Home Care
• Geriatric Care Management
• Home Modifications
• Seniors Services
• Adult Day Care
• Meals on Wheels

10. A Safe Trip Home
• Home Health (Medical)
• Molly’s points
• Molly’s points
• Molly’s points
• Home Care (Non-Medical)
• Assistance with ADL - Activities of Daily
Living
• Supports Home Health
• Private pay, LTC Insurance, Veterans Aid

11. Home Care
Home Health
Skilled Nursing
Geriatric Care!
Management

12. Sponsors