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DISCHARGE PLANNING TOOLKIT

ThistoolkitisofferedbyTheBeaconInstitutethroughagrantfromtheMarylandOfficeofHealthCareQuality

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DISCHARGEPLANNINGTOOLKITTABLEOFCONTENTS

Introduction

SECTIONI: STAFFRESOURCESNewRequirementsforDischargePlanningIncludesinformationonthenewMega-RulerequirementsforDischargePlanningthatbecameeffective11/28/17.Procedure/ChecklistforDischargePlanningToolformonitoringcompletionofnewMega-RulerequirementsDischargePlanningChecklistListofactionstoconsiderpriortoandonthedayofdischargeAssessmentofPost-DischargeNeedsChecklistofitemstoincludeinadischargeplanReadmissionRiskWorksheetListingoffactorsforincreasedriskofhospitalreadmission.DischargeCarePlanCareplanthatcanbeusedasis,orincorporatedintofacility’scareplanformat.BeingSensitivetoCulturalDifferencesFactorstoconsiderinrespecttoindividuals'beliefsandpractices;webresourcestogaininsightsaboutspecificgroupsResidentandCaregiverEducationReviewofitemswhichneedtobeconsideredforeffectiveeducationonpost-dischargecare.DischargePlanning:DiabeticManagementChecklistListingtoensureinclusionofessentialinformationneededfordiseasemanagement.MedicationReconciliationBlanktemplateMedicationAdministrationScheduleBlankTemplateDischargeSummarySuggestedContentGeneralguidelinefordischargedocumentation.DischargeSummary(Form)Blankformthatcanbecompletedandcopiedforresident/family/continuingcareproviders.OnlineResourcesforDischargePlanning/PreparationListingofwebresourceswithusefulinformationforstaff,resident,orcaregiverduringtheprocessofdischargeplanning.

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DISCHARGEPLANNINGTOOLKITINTRODUCTION

Dischargeplanninginvolvesacoordinatedeffortbetweenthepatient/resident,caregivingprofessionals,familymembers,andcommunitysupports.Itisintendedtosmooththetransitionfromfacilitycaretoahomesetting,oralternatefacility.Increasedattentionisbeingfocusedatdischargeprocessesduetopost-dischargecomplicationsandre-admissions.Accordingtoliteraturereports:

• 20%ofpatientsexperienceadverseeventswithin30daysofdischargefromhospitals

• 18%ofMedicarepatientsarereadmittedwithin30daysofdischarge• 40%ofpatients>65yearsoldexperiencepost-dischargemedication

errors• 30%ofnursinghomeshavebeenfoundtobenon-compliantwiththe

requirementsfordischargeplanning

InNovemberof2017,newrequirementsfordischargeplanningbecameeffectivewiththeimplementationofthenewMegaRule.Itisimportantforfacilitiestoreviewtheircurrentdischargeplanningprocessesandmakerevisionsasnecessaryforregulatorycomplianceandforimprovedquality.Thesenewrequirementsplaceincreasedemphasisonpatientgoalsandpreferences,andpreparationstocoordinateappropriatesupportstomeetthosegoals.

Post-dischargeneedsareoftenmulti-factorial,andoftenincludeeducationoftheresidentandfamilyonhealthconditions,medications,andfollow-upcare.Supportservicesmayinvolvebothclinicaland-non-clinicalservicesandbedirectedatnotonlythepatient,butfamilycaregiversaswell.Specialattentionmustalsobegiventoassessthereadinessofthefamilytoassumethecaregivingroleandtheimpactthatcaregivingwillhave.

Becauseofthenumberandvarietyofactivitiesthatmustbecarriedout,andthenumberofpeople/disciplinesinvolved,qualityimprovementinitiativesfordischargeplanningstronglyrecommendtheuseofchecklistsandtoolstoassurethatallneedshavebeenaddressed.Thepurposeofthistoolkitistoprovidepracticalinformationandresourcestofacilitateandsupportfacilityeffortstomeetdischargeplanningneeds.

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SECTIONI:STAFFRESOURCES

NEWREQUIREMENTSFORDISCHARGEPLANNING

F660(new)(oldtag=F284)483.21(c)(1)DischargePlanningProcess

Thefacilitymustdevelopandimplementaneffectivedischargeplanningprocessthatfocusesontheresident’sdischargegoals,thepreparationofresidentstobeactivepartners,andeffectivelytransitionthemtopost-dischargecare,andthereductionoffactorsleadingtopreventablereadmissions.Thefacility’sdischargeplanningprocessmustbeconsistentwiththedischargerightssetforat483.15(b)asapplicable,and–

(i) Ensurethatthedischargeneedsofeachresidentareidentifiedandresultinthedevelopmentofadischargeplanforeachresident

(ii) Includeregularre-evaluationofresidentstoidentifychangesthatrequiremodificationofthedischargeplan.Thedischargeplanmustbeupdated,asneeded,toreflectthosechanges.

(iii) Involvetheinterdisciplinaryteam,asdefinedby483.21(b)(2)(ii),intheongoingprocessofdevelopingthedischargeplan

(iv) Considercaregiver/supportpersonavailabilityandtheresident’sorcaregiver’s/supportperson(s)capacityandcapabilitytoperformrequiredcare,aspartoftheidentificationofdischargeneeds.

(v) Involvetheresidentandresidentrepresentativeinthedevelopmentofthedischargeplanandinformtheresidentandresidentrepresentativeofthefinalplan

(vi) Addresstheresident’sgoalsofcareandtreatmentpreferences.(vii) Documentthattheresidenthasbeenaskedabouttheirinterestinreceiving

informationregardingreturningtothecommunity.(A) Iftheresidentindicatesaninterestinreturningtothecommunity,thefacilitymust

documentanyreferralstolocalcontactagenciesorotherappropriateentitiesmadeforthispurpose.

(B) Facilitiesmustupdatearesident’scomprehensivecareplananddischargeplan,asappropriate,inresponsetoinformationreceivedfromreferralstolocalagenciesorotherappropriateentities.

(C) Ifdischargetothecommunityisdeterminedtonotbefeasible,thefacilitymustdocumentwhomadethedeterminationandwhy.

(viii) ForresidentswhoaretransferredtoanotherSNForwhoaredischargedtoaHHA,IRF,orLTCH,assistresidentsandtheirresidentrepresentativesinselectingapost-acutecareproviderbyusingdatathatincludes,butisnotlimitedtoSNF(skillednursingfacility),HHA(homehealthagency),IRF(inpatientrehabfacility),orLTCH(long-termcarehospital)standardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceusetotheextentthedataisavailable.Thefacilitymustensurethatthepost-acutecarestandardizedpatientassessmentdata,data

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onqualitymeasures,anddataonresourceuseisrelevantandapplicabletotheresident’sgoalsofcareandtreatmentpreferences.

(ix) Document,completeonatimelybasisbasedontheresident’sneeds,andincludeintheclinicalrecord,theevaluationoftheresident’sdischargeneedsanddischargeplan.Theresultsoftheevaluationmustbediscussedwiththeresidentorresident’srepresentative.Allrelevantresidentinformationmustbeincorporatedintothedischargeplantofacilitateitsimplementationandtoavoidunnecessarydelaysintheresidentdischargeortransfer.

KeyPointsfromInterpretiveGuidelinesfor483.21(c)(1)DischargePlanningProcess

• Thedischargecareplanispartofthecomprehensivecareplanandmust:o Bedevelopedbytheinterdisciplinaryteamo Involvedirectcommunicationwithresident(and/orresident’srepresentative)o Identifyneedsthatmustbeaddressedpriortodischarge(suchaseducation,

rehabilitation,caregiversupport/education)o Bere-evaluatedregularlyandupdatedwhentheresident’sneedsorgoals

changeo Documentresident’sinterestin,andanyreferralsmadetolocalagencieso Identifypost-dischargeneeds(nursing,therapyservices,medicalequipment,

modificationstothehome,ADLassistance)• Forresidentswhowanttobedischargedtothecommunity

o Familymembers,significantothersortheresident’srepresentativeshouldbeinvolvedinthisdetermination(withtheresident’spermission),unlesstheresidentisunabletoparticipateinthedischargeplanningprocess

o Thenursinghomeisresponsibleformakingreferralso Theresident,andifapplicable,theresident’srepresentative,shouldbemade

awarethatthelocalombudsmanisavailabletoprovideinformationandassistwithanytransitionsfromthenursinghome.

• ForthosewhowanttobedischargedtoanotherSNF,HHA,IRF,orLTCHthefacilitymust:

o Provideassistanceinfindinganappropriateproviderthatwillmeettheresident’sneeds,goals,andpreferences

o Providepubliclyavailablestandardizedqualitydata(suchasCMSNursingHomeCompare),andresourceusedataasavailable(example–numberofresidentsdischarged,preventableinfectionrates,etc.)andguidanceinhelpingtheresident/familyunderstanddata

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PROCEDURE/CHECKLISTFORDISCHARGEPLANNING

TASK

DATE

INITIAL

LOCATIONOFINFORMATION

Explore/documenttheresident’sinterestinreceivinginformationaboutdischargetothecommunity.

Determineresidentgoals&preferences.

Performassessmentofdischargeneeds–KNOWLEDGE/MANAGEMENTOFMEDICALCONDITION

Performassessmentofdischargeneeds–MEDICATIONKNOWLEDGEANDMANAGEMENT

Performassessmentofdischargeneeds–PHYSICALFUNCTIONING

Performassessmentofdischargeneeds–COMPLETIONOFIADLtasks

Performassessmentofdischargeneeds–HOMEMODIFICATIONS

Performassessmentofdischargeneeds–MEDICALEQUIPMENT

Performassessmentofdischargeneeds–HOMEHEALTHSERVICES

Performassessmentofdischargeneeds–NON-CLINICALHOMESUPPORTSERVICES

Performassessmentofdischargeneeds–F/UAPPOINTMENTS

Performassessmentofdischargeneeds–COMMUNITYSUPPORT

Determineavailablecapacityandcapabilityoffamily/caregiversupport

Interdisciplinarydischargeplandevelopedwithinputofresidentandresidentrepresentative

Dischargeplanaddressesallresidentgoalsandpreferences

Documentallreferralsandresponsetoreferrals

ProvidestandardizedqualityandresourcedataforSNF,HHA,IRF,LTCHasavailable.

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TASK

DATE

INITIAL

LOCATIONOFINFORMATION

Documentre-evaluationofdischargeplanandupdatestoresident/family

Ifdischargeisdeterminedinfeasible,documentwhomadethatdeterminationandreasonswhy.

Additionalcomments:

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Encourageandaddressquestions.

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ASSESSMENTOFPOST-DISCHARGENEEDSResident:______________________________AnticipatedDischargeDate:________________Considerneedsineachofthefollowingareastoidentifyspecificneedstobeincludedinthedischargeplan:MedicalCondition:______Typeofcareand/ormonitoringneeded______Follow-upappointments______Homehealthservices______Specialequipmentandsupplies______MedicationmanagementPhysicalFunction:______Limitations_____ ADL/IADLsupportneeded______Homemodificationsneeded______Non-clinicalhomeservicesneededMentalCapacity:______Cognitivefunction______Educationlevel/Understandingof conditionandcare______Mood/MotivationLifestyle:______Usualdaily/weeklyroutines______Eatinghabits/foodchoices______Physicalactivity/exercise______Impactofconditiononlifestyle______RealisticgoalsandexpectationsSafeHousing:______Appropriatehousingavailable______HomecaregiveravailableHomeEnvironment:______Suitablehousingavailable______Modificationsforphysicalfunctioning/safetyOther:

Caregiver:______Homecaregivermotivated andinterestedincaregiving role______Homecaregiveravailabilityto meetneedsandisphysically abletoprovidecare______Caregiverunderstandswhat care/servicestobeprovided______CaregiverhassupportsystemTransportation:______ServicesavailableFinancialResources:______SufficientforhousingandcareservicesCommunitySupport:______Social/Emotional/Spiritual support______Counseling

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READMISSIONRISKWORKSHEETResident:___________________________________________AnticipatedDischargeDate:_________Reviewthelistbelowtoidentifythefactorsthatplacetheresidentathigherriskforreadmissiontothehospital: MedicalCondition(s) _____HeartDisease _____LungDisease _____KidneyDisease _____Diabetes _____Cancer _____Stroke ImpairedFunction: _____Physicallimitations/frailty/deconditioning _____Cognitiveimpairment MentalHealth _____Depression/anxiety _____Substanceabuse HighRiskMedications _____Anticoagulants _____Insulin/oralhypoglycemicagents _____Digoxin _____Narcotics Other: _____Poorhealthliteracy _____Poorsocialsupport _____>1unplannedhospitalizationinlast6months*Foreachriskidentified,considercontributingfactorsandpotentialcomplicationsandincludeappropriateinterventionsindischargeplanning.

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DISCHARGECAREPLAN

Resident:___________________________________AnticipatedDischargeDate:___________DischargeDestination:_______________________________________________Caregiver(s)byname,relationship,andcontactinformation(ifapplicable):Dischargediagnoses:Medications(providedetailsonMedicationAdministrationScheduleform):

CarePlan

Goal ActionstoAchieveGoal

TargetDatetoAchieve

Comments

Residentwillbedischargedto(location)________________________________________On____________________(fillinanticipateddate/timefordischarge)

Discussresident’sgoalsandexpectationsfordischarge.Exploreavailableoptionsforplacementandservices.Identifyavailablecaregiverandcommunitysupports.

Residentwillvalidateunderstandingofcondition(s)andpost-dischargeneedsandcarebeforedischargedate.

Provideresident/caregiverteachingonmedicalconditions(s)inalanguageandlevelthatisunderstandable.Providehandouts/teachingmaterialsandresourcesina

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languageandappropriatelevelforunderstanding.Validateresident/caregiverunderstandingbyteach-backordemonstrationasappropriate.Set-upscheduleforpost-dischargeappointments.Providedates/timesandallappropriatecontactinformation.Arrangefortransportationforfollow-upcareasneeded.Arrangeforappropriatein-homeservicesandequipment.Providecontactinformationfortypesofservices,providersandschedulesforhomevisitsand/ordeliveries.

Residentwillcorrectlyidentifyallmedicationstobetakenbeforedischargedate.

Obtain/providenecessaryprescriptions.Performmedicationreconciliationpriortodischargetoverifyaccuracyofdischargemedicationlist.Foreachmedication,providewritteninformationonreasonforuse,dose,whentobetaken,howtobetaken,specialprecautions,aswellassigns/symptomsofadversereactionorsideeffecttoreporttohealthcareprovider.Assureinformationprovidedisinalanguage/levelresident&caregivercanunderstand.Haveresidentteach-backand/ordemonstratemedicationadministrationinformation.

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Residentwillvalidateknowledgeofhealthmanagementinspecialcircumstancesbydischargedate.

Provideinformation(inalanguageandlevelresident&familycanunderstand)onsignsandsymptomsthatnecessitatenotificationofthehealthcareprovider.Provideappropriateinformationon“sick-day”management.Provideappropriateinformationonemergency/disasterpreparationforhealthcareneeds.Providecontactinformationfornecessarysupportsandservicesasappropriate.

Residentwillverbalizeknowledgeofandwillingnesstotrylifestylemodificationstopromoteandmaintainoptimalhealthconditionandminimizecomplicationsbydateofdischarge.

Reviewlifestylechoicesandpatternswithresident.Reviewpros/consofchoicesrelatedtoimpactonhealthandfunction.Helpresidenttoidentifyacceptablemodificationstochoicesandpatternstopromoteimprovedhealthoutcomesandqualityoflife.

Resident/familywillverbalizeknowledgeandunderstandingofallfollow-upcareandappointmentsasofdateofdischarge.

Providelistofallappointmentsandreferralswithfullcontactinformationwithdischargeinstructions.Useteach-backmethodtoassurethatresident/familyunderstandsallplansforfollow-upcare.

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BEINGSENSITIVETOCULTURALDIFFERENCESBeliefs and practices are influenced by ethnic and religious backgrounds. Sensitivity todifferencesisessentialtogivinggoodcareanddevelopingrealisticdischargeplans.Belowaresomefactorstoconsider:

DietIt isusefultoaskresidentsaboutfoodpreferences. Somegroupshaverulesthatrestrict theeatingofcertain foodsor require fastingandotherpractices. Toassureresidents comply with special diets after discharge, it is important to recommenddietary plans that are compatible with the resident's cultural or religious practices.Forexample,manyJewswillfollowakosherdietwhichforbidsporkandshellfishandmeatandmilkproductsbeingservedatthesamemealorfromthesamedish.

Sabbath

Holidays and days of religious observance can vary among cultural groups. Forexample:Jews observe their Sabbath from sundown Friday to sundown Saturday and mayrefuse to engage in procedures during that time; Seventh-Day Adventists observeSaturday as their holy day; and the Islamic faith (Muslims) observe Friday as theSabbathandmayprayfivetimeseachdayfacingtowardMecca.ViewsonHealthandIllnessViews on health status can be influenced by one’s culture. For example, NativeAmericansbelievethatapersonmustbeinbalancewithnaturetohavegoodhealth;Asiansbelievethatillnessistheresultofanimbalanceofthebody’snegative(yin)andpositive(yang)forces.Someculturesfollowspecialpracticesrelatedtotheirhealth.Asiansmayuseherbsandacupuncture.Hispanicsmayusespecialhealers,suchasCurranderos.Their cultural background can influence theway people participate in their care.Asianresidents,forinstance,maybereluctanttoexpressdisagreementordiscomfort.Likewise,African-Americanresidentsmaybedistrustfulofnursinghomestaffduetoahistoryofprejudicialtreatment.

Peopleareindividualsandtherearedifferencesamongpeoplefromthesameculturalgroup.This emphasizes the importance of learning about the individual resident and treating theirpersonal values, beliefs, andpracticeswith respect. Thewebsitesof theorganizations listedbelowofferusefulinformationtoincreaseyourawarenessofculturaldifferences.BureauofIndianAffairshttp://www.doi.gov/bureau-indian-affairs.htmlNationalAsianPacificCenteronAginghttp://www.napca.orgNationalAssociationforHispanicElderlyhttp://www.anppm.orgNationalCenteronBlackAgedhttp://www.ncba-aged.org

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NationalHispanicCouncilonAginghttp://www.nhcoa.orgNationalIndianCouncilonAginghttp://www.nicoa.orgNationalResourceCenteronNativeAmericanAging

http://www.med.und.nodak.edu/depts/rural/nrcnaa/OfficeofMinorityHealthResourceCenterhttp://www.omhrc.govOrganizationofChineseAmericanshttp://www.ocanatl.org

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DISCHARGEPLANNING:DIABETICMANAGEMENTCHECKLIST

ResidentName:_______________________________________________________________ Room#:______________AnticipatedDischargeDate:_____________________________ Resident Family StaffSignature CommentsHasglucometerforhomeuse.

Describeswhentoperformfingerstick.

Demonstrateshowtoperformfingerstick.

Accuratelyidentifies,prepares&administersoralmedicine.

Accuratelyidentifiesandpreparesinjectablemedicine.

Describesproperdisposalofsharpsinthehomeandhasappropriateequipment/supplies.

Describessigns/symptomsofhypoglycemiaandwhattodoinresponse.

Describessigns/symptomsofhyperglycemiaandwhattodoinresponse.

Describesappropriatefoodchoicesfordiet.

Describestheeffectofexerciseindiabetesmanagement.

Hasaplanforexerciseroutine.

Describes“sickday”managementand/orfastingforlabs/diagnostics.

Describesproperfootcare.

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MEDICATIONADMINISTRATIONSCHEDULE

Medication Dose&

RouteTime(s)toTake

SpecialInstructions SideEffects

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DISCHARGESUMMARYSUGGESTEDCONTENTDocumentationshouldbeincludedintherecordoftheresidentbeingdischargedthatincludesasummaryoftheresident'sstay,including:

• Reasonforadmission• Diagnoses• Statusatadmission(e.g.,nutritionalstatus,ambulation,functionalstatus,

independenceinperformingADLs,continence,mentalstatus)• Symptomspresented• Treatments/therapiesprovided• Medications• Anyunusualoccurrences• Residentandfamily/caregiver'spreferenceforcare• Statusatdischarge(e.g.,levelofindependence,mentalstatus,functionalstatus)

Includeadescriptionoftheplansdiscussedwiththeresidentandanyotherpersonswhowillserveascaregiversorwhotheresidentdesirestohavepresent.Consideranypotentialproblemsthatcouldbeanticipatedpostdischarge(e.g.,lackofconsistentcaregiversupport,homesituation,culturaldifferences,lackofresources,physicalormentalcompetencies,poormotivation,historyofnoncompliance)andhowtheycanbeaddressed.Section1861(ee)oftheSocialSecurityActrequiresthatMedicareparticipatingfacilitiesprovideresidentsbeingdischargedwithalistofMedicare-certifiedhomehealthagenciesinthegeographicareainwhichtheyreside,ifsuchcareisneeded.Referralsshouldbemadetomedicalequipmentsuppliers,communityresources,andanyotherservicesthattheresidentmayneedpost-discharge.Informationshouldbetransmittedwithin7daystothemedicalproviderwhowillbeinvolvedwiththeresidentafterdischarge.

Postdischargeplansshouldinclude:

• Generalgoals• Treatmentsandothercarerequired• Diet,anydietaryinstructions/restrictions• Assistanceresidentneedswithbathing,dressing,transfer,feeding,toileting;

instructionsspecifictoresidentforprovidingnecessaryassistance• Whowillprovideanyassistanceresidentwillneed• Medications:purpose,scheduleforadministration,dosage,anyspecial

instructions/precautions,sideeffects,reactionstocallproviderabout• Unusualsignstoreporttomedicalprovider;whentoobtainemergencyassistance• Appointmentsformedicalfollowup;transportationarrangementsforappointments• Anticipatedlevelofindependence

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DISCHARGESUMMARY(FORM)

ResidentName:_________________________________________Room#:____________________D.O.B.________________GenderIdentification:______DateofDischarge:_____________________SUMMARYOFTHERESIDENT’SSTAY:Diagnoses/HealthConditions:ReasonforAdmission:CourseofIllness/TreatmentWhileinFacility:Symptoms:FunctionalStatus:PertinentResultsforLabs/Radiology/Consults:Treatments/TherapiesProvided:OtherProcedures:UnusualOccurrences/Complications:STATUSATTIMEOFDISCHARGE:DescribeMentalStatus:DescribeMood&Behavior:DescribePsychosocialstatus:

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DISCHARGESUMMARY(continued)CommunicationPatterns(circleresponses):Hearing:adequate minimaldifficulty moderatedifficulty highlyimpairedUseshearingaid: Yes NoSpeech:clearlyunderstoodusuallyunderstood sometimesunderstood rarelyunderstoodNativelanguage:Vision:adequateIfimpaired:minimal moderate high severeCorrectiveLensesused: Yes No Glasses ContactsDescribedeficits/abilities:Dental/OralHealthIssues:NutritionalStatus:SkinCondition:ContinenceStatus:CustomaryRoutine:ActivityPursuit:SummaryofAdditionalAssessments(CAAs)fromTriggeredMDSItems:MedicationsatDischarge:(Pleaseattachlist)DischargePlan:(Pleaseattach)ComprehensiveCarePlanGoals:

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DISCHARGESUMMARY(continued)AdvanceDirectives:(Pleaseattach)SpecialInstructions/Precautions:Whoparticipatedinassessment:Resident_____Family______Othercaregiver________ContactInfo:HealthCareProviderfromTransferringFacility:____________________________________________________________________________________________ResidentRepresentative:_________________________

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ONLINERESOURCESFORDISCHARGEPLANNING/PREPARATION

http://www.justiceinaging.org/wp-content/uploads/2016/12/A-Guide-to-the-Revised-Nursing-Facility-Regulations.pdfContainsasynopsisofupcomingchangesinthefederalnursinghomeregulationsrelatedtodischargeplanningthatbecomeeffectiveinNovember2017.https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4 Tool 1 IDEAL chklst 508.pdfExcellentresourceentitledIDEALDischargePlanningOverview,Process,andChecklistfromtheAgencyforHealthcareResearchandQuality.Providesguidanceforthedischargeprocesstoengageresidentsandfamiliesalongwithusefulchecklists.https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/institutional-care/downloads/hospital-discharge-checklist.pdfThefeaturedbrochureonthissiteisfromCMS.Itcontainsachecklistofalldischargeplanningitemsforresident/familyreviewtoassureresidentpreparedfordischarge.https://www.caregiver.org/hospital-discharge-planning-guide-families-and-caregiversFromtheFamilyCaregiverAlliance,thisdocumentprovidesguidanceforresidents/familiesondischargeplanning.http://www.nextstepincare.org/Siteprovidesmultiplelinkstoguidanceandtoolstoassistboththehomecaregiverandtheprofessionalintheprocessofdischargepreparationandtransitiontohome.InformationisavailableinEnglish,Spanish,Russian,andChinese.https://consultgeri.org/try-this/general-assessment/issue-22.pdfChecklisttoassessafamilymember’spreferencesforinvolvementincare.

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SECTIONII:RESIDENTANDCAREGIVERRESOURCES

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MEDICATIONSAFETY

Medicationshavemanybenefits,buttheycancauseproblemsifnotusedcorrectly.Thisistrueforbothprescriptiondrugsandover-the-counterdrugs.Herearesometipstohelpyouusemedicationssafely.

PrescriptionDrugs• Foreachdrugyouareprescribedknow:

o Thereasonthedrugwasorderedo Thetime(s)itistobetakeno Howitshouldbetaken(bymouth,injected,withfood,withoutfood,etc)o Thesideeffectsthedrugandwhichsideeffectsareseriousenoughtobebroughtto

yourmedicalprovider'sattentiono Howlongyoushouldtakethedrug

Over-TheCounterDrugs• Discusstheuseofthedrugwithyourmedicalproviderbeforeusingit

o Manyover-the-counterdrugscaninteractwithyourprescriptiondrugsandcauseproblems

• Readthelabelcarefullytounderstand:o Whatthedrugisusedforo Thedosageo Howoftenyoushouldtakeito Sideeffectso Anyprecautions

ForAllDrugs• Makesurethemedicalproviderwhoprescribesanewdrugknowsallthedrugs(prescription

andnonprescription)andanyvitamins,herbsorothersupplementsthatarebeingtakenasthesecanhaveseriousinteractionswitheachother

• Followinstructionscarefully.• Measurethedosecarefully.• Useapillorganizerinwhichyoucanourpillsforeachdayoftheweektohelpyourememberif

you'vetakenthem.• Useadosagecuporsyringetomeasureliquidmedications.Ifyouhavetroubledrinkingoutofa

cup,youcanuseadropperorsyringetoputtheliquidmedicationinandadministerit.• Keepdrugsintheiroriginalcontainer.• Knowifthedrugsneedtobestoredinanyspecialway,suchasintherefrigerator.• Don'tuseanyoneelse'sdrugsanddon'tletanyoneelseuseyours.• Makesureyoukeepyourmedicationsinaplacewherechildrenorsomeoneconfusedcan't

reachthem.• Notifyyourmedicalproviderifyoustarttohaveanyoftheadversereactionstothe

drug.• Takeallofyourmedicationswithyoutoallmedicalappointments.

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ONLINERESOURCES

Thefollowingwebsitesaregoodsitestoobtaininformationonspecificissuesforuseinteachingresidentsandcaregivers.

HEALTHCONDITIONS

www.emedicinehealth.comThissitecontainsawealthofhealthinformationonalargevarietyofhealthconditions.Informationincludesanexplanationoftopics,symptoms,treatment,andpersonalmanagement.Manytopicsalsohaverelatedquizzesandslideshowpresentationsthatcanbeusedfordischargeteaching.Wellworthexploringforhelpfulinformation.

ADVANCEDIRECTIVES/MOLST

http://www.marylandattorneygeneral.gov/Health%20Policy%20Documents/adirective.pdfContainsan18pagebookletfromtheMarylandAttorneyGeneral’sOfficethatservesasaguidetoMarylandlawandplanningforhealthcaredecisions.IncludesformsthatcanbeusedtocreateanAdvanceDirective.

http://mhcc.maryland.gov/consumerinfo/longtermcare/AdvanceDirectiveInformation.aspxInformationpageentitled“ConsumerGuidetoLongTermCare”thatexplainsAdvanceDirectivesandincludeslinkstoresourcestohelpwithadvancedplanning.

http://www.marylandattorneygeneral.gov/Pages/HealthPolicy/AdvanceDirectives.aspxEnlargedprintversionofinformation/formsforAdvanceDirectivesinMaryland.

http://marylandmolst.org/ExplainstheMOLSTformusedinMarylandformedicalordersforlifesavingtreatment.Containsalinktotheformaswellastoresourcesforadditionalinformation.

ALZHEIMER'SDISEASE

https://www.alz.org/health-care-professionals/patient-information-education-care-resources.asp

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Thissighthasawealthofinformationforthehomecaregiver,includingeducationmaterialsandcommunityandonlineresources.EducationmaterialsareavailableinSpanish,Japanese,Korean,Chinese,andVietnamese.Topicsinclude:Med-AlertandSafe-ReturnProgram,dailycare,communication,behaviormanagement,caregivertips,safety,anddisasterplanningamongothers.*Informationcanbeeasilydownloadedandprintedfordistributiontofamilies.

ALZHEIMER'SDISEASE(cont.)

24/7Helpline–1-800-272-3900TDD1-866-403-3073Offersinformation,support,referrals,andcrisishelp.Languagetranslationservicesareavailable.

ANTICOAGULANTTHERAPY

https://health.ucsd.edu/specialties/anticoagulation/patients/Pages/default.aspxContainsavarietyofeducationalmaterials,includingan11-pagebooklettitled“YourGuidetoAnticoagulationTherapy”whichprovidesasimple,easytoreadexplanationofimportantinformationapatientshouldknowaboutwarfarintherapy.Alsoprovidesasampleofanemergencymedicalcardthatcanbekeptinawallettoalertemergencyresponderstowarfarintherapyandtheconditionthatitistreating.AdditionalinformationincludesahelpfulsectiononFrequentlyAskedQuestions,DrugInteractions,andinformationabouttakingwarfarinandvitaminK.Thereisalsoa2-pageguidetoCoumadin.Itisinrelativelysimplelanguage,butthereisalotofinformationpackedintothe2pages.Considerthereading/comprehensionabilityoftheresident.

http://www.uptodate.com/contents/warfarin-coumadin-beyond-the-basicsProvidesforagoodoverviewofwarfarintherapy.Therearealsoalotoflinkstoothercrediblewebsitesthatprovideinformationonvarioushealthconditionsrequiringwarfarintherapy.Linksarecategorizedin3sections:simple/easytoreadoverview;intermediatelevelthatcontainsabitmoreinformation,andprofessionallevelmaterials.

ARTHRITIS

http://www.arthritis.orgProvidesawealthofinformationaboutlivingwitharthritisincludinganexplanationofthecondition,treatments,painmanagement,exercise,andmood.Thereareavarietyoftoolsincludingpainquestionnaires,paindiary,andapainmanagementplan.Therearealsonumerousconnectionstootherresourcesincludingshortvideosonarthritisfriendlyexercise

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programs,printedmaterials,andsupportnetworks.InformationisavailableinSpanishaswellasEnglish.https://www.curearthritis.orgThisorganization’sprimaryfocusisonresearch,butthereissomehelpfulinformationtodescribevarioustypesofarthritis.https://www.ncoa.org/resources/osteoarthritis-and-falls/Brochurethatexplainsosteoarthritisanddiscussesfallriskandprevention.https://www.hopkinsarthritis.org/patient-corner/Goodresourceforspecificinformationsheetsfordrugscommonlyusedfortreatmentofarthritis.HassomeadditionalinformationonassistivedevicestohelpwithADLs/IADLsandalternatetherapies.CHRONICOBSTRUCTIVEPULMONARYDISEASE(COPD)www.lung.org/lung-health-and-disease-lookup/copd/CoversavarietyoftopicsincludingCOPDsymptoms,causes,risks,treatments,andlivingwithCOPD.Includesquestionstoaskdoctorandlinkstosmokingcessationinformation.Thereisahelplinethatcanbeaccessedat1-800-LUNGUSAforfreehelpfromacounselor.Freeonlinechatwithacounselorisalsoavailable.ThereisatabtoaccessinformationinSpanish.http://www.thoracic.org/patients/patient-resources/resources/copd-intro.pdfTwo-pagereviewofCOPDdesignedforpatientuse,includingexplanationofconditionandtreatment.Diagramsincluded.https://www.nhlbi.nih.gov/health/health-topics/topics/copdTopicscoveredincludeanexplanationofCOPD,riskfactors,signs&symptoms,diagnosis&treatment,prevention,livingwithCOPD.Alsoincludesshortvideoclipsthatcouldbeusedforpatientteaching.Additionalinformationontopicssuchashowthelungswork,oxygenuse,smokingcessation,healthyheartandmoreisincluded.MuchofthematerialisavailableinSpanish.https://familydoctor.org/how-to-use-a-metered-dose-inhaler/Informationonhowtouseametered-doseinhalerandotherconsiderationsforinhalationtherapy.https://www.cdc.gov/asthma/inhaler video/default.htmContainsvideosonhowtouseametered-doseinhalerinbothEnglishandSpanish.Canbeusedforpatienteducation.

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http://www.safemedication.com/safemed/MedicationTipsTools/HowtoAdminister/HowtoUseMeteredDoseInhalersSimpleguideincludingillustrationsonhowtouseametered-doseinhaler.CONGESTIVEHEARTFAILUREhttp://www.calheart.org/handler.cfm?event=practice,template&cpid=10756Handoutwithexplanationoftheconditionwithgooddiagrams.www.emedicinehealth.com/congestive heart failure/article em.htmGoodinformationonmultipleaspectsofheartfunctionandcongestiveheartfailureanditssymptoms,includingquizandslideshow.Multiplelinkstorelatedhealthconditionsorinformation.https://www.ucsfhealth.org/education/diet and congestive heart failure/GoodinformationtoguidedietchoicesformanagementofCHF.CULTURALDIFFERENCEShttps://www.euromedinfo.eu/how-culture-influences-health-beliefs.html/Siteprovidesusefulinformationtohelpunderstandtheattitudesandbeliefsabouthealthcareinothercultures.Topicspresentedonthepagesofthesiteinclude:differencesinhealthattitudes,performingaculturalassessment,negotiatinghealthdecisionswithsomeonefromadifferentculture,communicationwithnon-Englishspeakingpatients,theuseoftranslatorsandinterpreters,anddevelopingculturalcompetence.DIABETESMELLITUShttp://www.hopkinsmedicine.org/gim/core resources/Patient%20Handouts/InformationavailableonTypes1and2,specificgenderissuesanddiabetes,lifestyle,glucosetesting,hyper-andhypoglycemia,footcare,rotationofinjectionsites,exercise,dietandweightloss,alcoholuseanddiabetes,smokinganddiabetes,sickdayguidelinesanddiabetesrelatedtoheartandkidneydisease.http://www.diabetes.org/research-and-practice/we-support-your-doctor/patient-education-materials.html?referrer=https://search.yahoo.com/andhttp://professional.diabetes.org/content/diabetes-educator-resources

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IncludeslinktoPatientEducationLibraryforavarietyofeducationmaterialsonthecondition,management,emotionalwell-being,nutrition,etc.Searchcanbefiltered(onrightscreen)bycategoryofinformationandavailablelanguages(Arabic,Chinese,English,French,HaitianCreole,Korean,Portuguese,Russian,Spanish,Tagalog,andVietnamese).www.emedicinehealth.com(searchfor‘diabetes’)Containslargevarietyofinformationondiabetes,livingwithdiabetes,complications,specialissues(sickday,travelling,emergency/disaster,etc.).Includesseveralquizzesandslideshowsthatcanbeusedforteaching.FALLPREVENTIONhttps://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.htmlProvidesgeneralinformationaboutfallsandolderadultsandlinkstootherarticlesandresources.https://www.cdc.gov/steadi/pdf/STEADI OlderAdultFactSheet-a.pdfHandoutforolderadults,withgeneralinformationaboutfallsandtipsforprevention.https://www.cdc.gov/steadi/pdf/Stay Independent brochure-a.pdfBrochurewithriskquestionnaireandbasicinformationaboutsafetymeasuresforprevention.AlsoavailableinSpanish.https://www.cdc.gov/steadi/pdf/STEADI CaregiverBrochure-a.pdfhttps://www.ncoa.org/healthy-aging/falls-prevention/preventing-falls-tips-for-older-adults-and-caregivers/6-steps-to-protect-your-older-loved-one-from-a-fall/Bothofthesesitesofferinformationforfamilycaregiversaboutfallsandsafetymeasuresforprevention.https://www.cdc.gov/steadi/pdf/STEADI CheckforSafety brochure-a.pdfUsefulchecklistthatguidesapersontocheckforsafetyissuesthroughoutthevariousroomsinthehome.AlsoavailableinSpanish.Pre-printedbrochuresinChinesecanbeorderedfromthesite.https://www.cdc.gov/steadi/pdf/What You Can Do brochure-a.pdfBrochurethatdiscusseswhatapersoncandotoreducetheriskoffalling.SpanishandChineseversionscanbeprintedfromthesite.https://www.ncoa.org/resources/osteoarthritis-and-falls/Brochurethatexplainsosteoarthritisandfallsriskandprevention.

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https://cfosm.com/patient-education/kb/hw-view.php?DOCHWID=aa6973Providesinformationonhipfractures,includingrisksforfracture,anexplanationofthecondition,aswellashowitistreated.HIGHBLOODPRESSURE(HYPERTENSION)https://www.cdc.gov/bloodpressure/materials for patients.htmThissiteprovideslinkstonumerouseducationalmaterialsonhighbloodpressureandrelatedconditions.TherearesomespecificmaterialsinSpanishthatrelatetobloodpressuremanagementintheHispanicpopulation.http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure-or-Hypertension UCM 002020 SubHomePage.jspAmericanHeartAssociationmaterialsthatexplainbloodpressureandhowitcanbemanaged.Alsocontainslinkstomaterialsonrelatedheartconditions.https://www.cdc.gov/bloodpressure/docs/ConsumerEd HBP.pdfPatientinformationsheetwithbasicinformationaboutbloodpressureanditsmanagement.http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm 300625.pdfPatientinformationsheetonlimitingsaltindietforbloodpressuremanagement.JOINTREPLACEMENTSURGERYhttp://www.arthritis.org/living-with-arthritis/treatments/joint-surgery/preparing/post-surgery-recovery.phpInformationsheetwithtipstopreparethehomeforpost-surgerydischarge.https://www.niams.nih.gov/health info/joint replacement/#7Informationonwhattoexpectfollowingjointreplacementtherapyanddescriptionsofadversethingstowatchoutfor(bloodclots,infection,etc.)http://www.healthline.com/health/preparing-your-home-knee-replacement-recovery#2http://www.healthline.com/health/total-knee-replacement-surgery/follow-up-appointments#1BothofthesesitesprovideInformationonrecoveryfromkneesurgery.Slideshowsareavailablethatmayhelpwithpatientteaching.

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LOWVISION

http://www.allaboutvision.com/lowvision/resources.htmThiswebpageprovideshelpfulresourcesforlearningaboutbenefitsthatareavailableforthosewithlowvision,aswellaslinkstoanumberoforganizationsandappsthatprovidelowvisionservicesandresources.

http://www.seniorvision.org/resources/coping-with-visual-impairmentProvidesgood,easy-to-followinformationonhowtorecognizevisualproblemsinalovedone,andsimpleguidanceforcommunicationandprovidingassistance.

https://www.agingcare.com/articles/helping-your-loved-one-live-with-low-vision-111675.htmhttps://www.agingcare.com/articles/making-life-easier-for-older-adults-with-low-vision-177792.htmBothofthesearticlesprovideeasytofollow,usefultipsforhelpingsomeonewithlowvision.

MEDICATIONEDUCATION

http://www.safemedication.com/default.aspxAverygoodresourceformedicationinformationforresidentsbeingdischarged.Cantypeinnameofmedicationanditwilltakeyoutoalistingforthatinformation.Clickingonthenameoftheappropriatemedicationwilltakeyoutoinformationaboutwhythedoctorordersthatmedication,howtotakethemedication,specialinstructions,sideeffects,etc.

http://www.safemedication.com/safemed/MyMedicineList/MyMedicineList 1.aspxAusefultemplatecalled“MyMedicationList”toreviewmedicationsthatthepersonmaybetaking(prescriptionandnon-prescription).

http://www.nextstepincare.org/uploads/File/Guides/Medication/Medication ManagementGuide/Medication Management.pdfProvidesinformationforthefamilycaregiveronmedicationmanagement,includinghowtoreadmedicationlabels,adistinctionbetweenprescription,over-the-counter,andherbalmedications,maintainingacurrentlistofmedications,andcommonquestions/problemsrelatedtoprescriptionmanagement.ItisavailableinEnglish,Spanish,Russian,andChinese.

OXYGENSAFETY

https://patienteducation.osumc.edu/Documents/ox-sf-rg.pdfOnepageinformationsheetonsafetytipsforoxygenuseinthehome.

https://www.ucsfhealth.org/education/supplemental oxygen/oxygen safety/

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Discussionofoxygensafetyandlinkstoothersupplementaloxygeninformation,includingtravellingwithoxygen.

PNEUMONIA

http://www.upmc.com/patients-visitors/education/breathing/Pages/pneumonia.aspxGeneralinformationsheetontypesofpneumonia,signsandsymptoms,treatmentandmanagement,andprevention.

http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/InformationprovidedbytheAmericanLungAssociation.Providesgeneralexplanationofpneumoniawithvariouslinkstorelatedinformation(includingvaccinationunder‘prevention’).ThereisatabfortranslationintoSpanish.

STROKE

http://www.strokecenter.org/wp-content/uploads/2011/08/Recovering-After-a-Stroke.pdfA17-pagebookletthatdiscussesvariousaspectsofcarefollowingastroke.(Publicationdateislistedas1995,butcontentprovidedisstillrelevant.)

http://www.strokecenter.org/wp-content/uploads/2011/08/Stroke-Recovery-Guide.pdfAcomprehensive76-pageguidetovariousaspectsoflifeafterastroke.Whileprintingofftheentirebookletmaybeexcessive,therearepartswhichmaybespecificallyrelevanttoaresident’sconditionorafamily’sneedthatcouldbecopiedandprinted.

https://www.cdc.gov/stroke/materials for patients.htmLinkstovariousinformationsheetsandeducationmaterialsforstrokeaswellasforotherchronicconditionsthatincreasetheriskforstroke.SomematerialsavailableinSpanish.

https://www.cdc.gov/stroke/docs/consumered stroke.pdf“KnowtheFactsAboutStroke”–2pagepatienthandout.

SUBTANCEABUSE

https://www.centeronaddiction.org/addiction/commonly-used-illegal-drugsInformationsheetthatidentifiescommonlyusedillegaldrugs,howtheyareused,theireffectsandhealthrisks.

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http://www.casacolumbia.org/sites/default/files/files/Final-patient-guide-april-2014.pdfTwenty-twopagebookletwithhelpfulinformationaboutunderstandingandassessingaddictionaswellasinfotohelpinrecovery.Maybeausefulguideforstaff.http://www.projectknow.com/research/resources/Siteprovidesnumerouslinkstoavarietyofinformationaboutaddiction,substancesthatareabused(alcohol,tobacco,prescriptionandillegaldrugs),behavioralhealthissues,treatments,tipsforsuccess,risksforrelapse,andcopingwithrelapse.Helpfulguidetohelpstafftounderstandtheconditionandtheneedsofthepersonwithanaddiction.http://www.projectknow.com/research/prescription-drug-by-type/Providesahelpfulguideforstaffontheaddictiontovarioustypesofprescriptiondrugs;alsoprovidesdetoxandwithdrawalinformation,theeffectsofoverdose,andrehabilitation.https://www.alcohollearningcentre.org.uk/Topics/Latest/Severity-of-Alcohol-Dependence-Questionnaire-SADQ/ProvidesalinktotheSeverityofAlcoholDependenceQuestionnaire.Alsoprovidesinformationastohowtoscoreandinterpretresults.https://bha.health.maryland.gov/NALOXONE/Pages/Naloxone.aspxIncludesinformationabouthowtoobtainandusenaloxone(Narcan,Evzio)intheeventofanopioidoverdose.ContainsvariouslinkstoaccessusefulinformationsuchastheMarylandOverdoseResponseProgram,trainingsites,andpharmaciesparticipatingintheprogramforaccesstothedrug.https://bha.health.maryland.gov/NALOXONE/Pages/Home.aspxThewebsitefortheMarylandOverdoseResponseProgram.Providesvariouslinkstotrainingcalendars,andtrainingcenters,statewidestandingorder,andotheradditionalresources.https://bha.health.maryland.gov/NALOXONE/Documents/Narcan%20Nasal%20Spray%20Brochure%20final.pdfBrochurethatshowshowtorecognizesignsofanoverdoseanddepictionofhowtoadministernaloxoneandfollow-upstepsuntilemergencyresponsearrives.http://prescribetoprevent.org/Containslinkstoeducationonoverdoseriskanduseofnaloxone.https://bha.health.maryland.gov/NALOXONE/Documents/The%20Maryland%20Overdose%20Response%20Program%20-%20Directory%20August%208,%202017.pdfContactinformationforcentersthroughoutMarylandthatparticipateintheOverdoseResponseProgram.Alsoincludesalinktothetrainingcalendarfordates/locationsoftraining.

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URINARYINCONTINENCEhttps://www.mskcc.org/cancer-care/patient-education/improving-your-urinary-continencePatientinformationsheetontipstomanageurinaryincontinence.https://www.scanhealthplan.com/providers/clinical-guidelines-and-practice-tools/urinary-incontinence/patient-education-resourcesNIHpatientbrochureonurinaryincontinence.AvailableinSpanish.