Life is often unpredictable. One moment you can be at home celebrating a birthday or anniversary sharing laughs with friends and family. The next day you can find yourself in a hospital room surrounded by wires and beeping alarms. Even the individuals we deem “healthiest” in our society can be thrust into a hospital in a moment’s notice. You and your loved ones must think about medical bills, insurance coverage, medical equipment, medications, and on and on. The decisions that must be made are too long for a single blog post. Through Navigating Home with Minds Matter, we believe a successful journey home begins with conversations at the side of a hospital bed with the individual at the center of the conversation.
What happens next? Smooth transitions start by asking the person a simple, but often overlooked question: “where do YOU want to go when you leave the hospital?” That one single question sets out the course, and provides grounding, to every decision that dominos. We at Minds Matter believe everyone deserves the choice to live, work, and play in their community. Through our Person-Centered approach, we can remain aligned with what you, as the consumer, want to have taken place and provide resources and guidance along the way.
After determining the where, we can begin to lay out the road map to reach the destination. For most people, the answer to the above question is, “I want to go back home.” Here are some questions that need to be answered:
- What happens from hospital to home?
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- Begin having intentional conversations with medical professionals and hospital staff. Ask their recommendations regarding the plan of care, rehab hospital stays and gain valuable insight into training that may be needed.
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- What formal and informal support is needed to be successful at home?
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- Start identifying friends and family that can help at home and determine how many hours are needed. Think about what you need help with on your worst day.
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- Will I need any modifications to the home, or is there any equipment needed?
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- Begin taking pictures and measurements of the home; bathroom doorways tend to be smaller than exterior and bedroom doorways. Think about whether a wheelchair, grab bars, ramps, or other equipment is needed and if theses will fit in the home.
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- Will I be able to keep my current insurance, or do I need to apply for Medicaid and a waiver?
- If marketplace or commercial premiums are high or if these will not remain active, it may be appropriate to apply for Medicaid. If you are applying for Medicaid, then a Social Security claim (SSA) and Presumptive Medical Disability (PMD) should accompany this process.
- Medicaid has multiple waivers that serve various needs. The Kansas Brain Injury Waiver provides rehabilitation. Contact the Aging and Disability Resource Center (ADRC)
- If marketplace or commercial premiums are high or if these will not remain active, it may be appropriate to apply for Medicaid. If you are applying for Medicaid, then a Social Security claim (SSA) and Presumptive Medical Disability (PMD) should accompany this process.
- What therapy will be needed at the time of discharge?
- Most insurance companies will have in-network and out-of-network Home Health agencies and outpatient clinics.
- What healthcare follow-ups will be needed after discharge?
- Typically, initial medications and scripts will be ordered but continued follow up will take place with a primary care physician. Referrals may need to take place for specialists (cardiology, neurology, etc.).
- You may be placed on new medications or have to administer them in a new way. Prior to discharge, discuss medications with your healthcare professionals and ask for multiple training sessions to take place. Recordings of training sessions on a cell phone or tablet are a clever way to reference skills learned in the hospital.
- Typically, initial medications and scripts will be ordered but continued follow up will take place with a primary care physician. Referrals may need to take place for specialists (cardiology, neurology, etc.).
A successful return home is not something that happens by accident. It takes intentional conversations, open dialogue, and confidence that all the necessary voices are at the table. Minds Matter does this through taking the time to slow down and foster a safe space where this can take place. We have developed a well-organized checklist to reduce uncertainty and ensure important steps are not overlooked. Please connect with Minds Matter’s Navigating Home Program for guidance and support throughout the process.
-Written by Matt Kaiser, Navigating Home Specialist with Minds Matter, LLC
