Plan Ahead for Long-Term Care

Most people do not think about long-term care until a health crisis happens. But waiting can make it harder for families to make important decisions.

Tiffany Fields, LCSW, social services manager at Bayhealth, encourages people to start planning before they need care.

"Long-term care planning means thinking ahead about the care you may need as you get older, become sick or have a disability," Fields said. "Planning now gives you and your family time to make thoughtful decisions before an emergency."

Long-term care planning is about more than deciding where you live. It also includes:

• Choosing who will make healthcare decisions for you if you cannot.
• Talking with loved ones about your wishes.
• Learning how you can pay for future care.
• Finding community services that may help you stay safe and independent.

These conversations are not always easy, but they can make a difficult time less stressful. Planning ahead also helps make sure your wishes are known.

"Whether you're planning for yourself, your parents or another loved one, it's never too early to start the conversation," Fields said.

Planning Starts on Day One

Many people think planning for what happens after you leave the hospital – also known as discharge planning – begins when you are ready to leave the hospital. That is not the case.

At Bayhealth, discharge planning begins as soon as a patient is admitted. The goal is to help you recover safely, avoid complications and reduce the chance that you'll need to return to the hospital.

A discharge plan may include:

• When you'll go home or move to another facility, such as a rehabilitation center.
• What medications you need to take and how to take them.
• Instructions for caring for yourself, such as changing bandages, eating certain foods or limiting activities.
• Follow-up appointments with your primary care clinician or specialists.
• Medical equipment you may need, such as a walker, wheelchair or oxygen.
• Home health services, physical therapy or other support.
• Information about who to call if you have questions or your condition changes.

"We say discharge planning starts on day one," Fields said. "Patients are sometimes surprised when a social worker or care manager visits soon after they arrive. But starting early helps us plan for the care they will need after they leave the hospital."

Starting early gives the care team time to learn about each patient's needs. They can arrange services, answer questions and solve problems before discharge. This helps patients move safely from the hospital to home or another care setting.

Understanding the Hospital's Role

Hospitals are designed to treat people who are sick, injured or having a medical emergency.

"Our job is to provide short-term medical care," Fields said.

When patients are well enough to leave the hospital, the care team helps decide what should happen next. Some people return home with support services. Others may need short-term rehabilitation or long-term care.

Hospitals are not meant to provide long-term housing or daily personal care.

Staying in the hospital longer than needed can increase health risks and reduce space for patients who need emergency care. That is why Bayhealth begins planning for discharge as early as possible.

A Team Effort

Many people work together to help patients leave the hospital safely. This includes doctors, nurses, care managers, social workers, therapists, patients and their loved ones.

The care team meets every day to review each patient's progress and discuss what they will need after leaving the hospital.

"The goal is to make sure everyone is working together," Fields said. "If we find a problem early, we have more time to help."

The care management team also talks with patients and families about where they live, who can help them at home and what challenges they may face after discharge.

"Our goal is to have the right services in place before the patient is ready to leave the hospital," Fields said.

Common Challenges

Many things can affect when someone leaves the hospital. Insurance coverage, transportation, family support and finding an available care facility can all take time.

One common challenge is paying for rehabilitation or long-term care.

"When people need these services, they may not know how they will pay for them," Fields said.

Bayhealth's care management team helps patients learn about programs such as Medicaid and other financial resources that may be available.

Family caregivers can also become overwhelmed.

"We often meet caregivers who want to help but need support themselves," Fields said.

The team connects families with community resources, including home healthcare, caregiver support, services for older adults, housing resources and substance use treatment programs when needed.

Bayhealth has also created a long-term care planning guide that patients and families can use after leaving the hospital.

"It's a one-stop resource that explains available services and where to find help," Fields said.

Start Planning Today

Fields encourages adults of every age to prepare for the future.

"Even if you're 22 years old, you should have a power of attorney because you never know what can happen," she said.

Planning ahead cannot prevent illness or emergencies. But it can make them easier to manage.

"Even if you're healthy today, you don't know what tomorrow may bring," Fields said. "The best thing you can do is be prepared."

Talk with your loved ones about your healthcare wishes. Choose someone you trust to make decisions for you if you cannot. Put your wishes in writing and learn about resources that may help if you or a family member ever need long-term care.

To learn more about Bayhealth's services and community resources, visit Bayhealth.org or speak with your primary care clinician.