When you are ready to leave the hospital or rehabilitation centre, you will need to make a plan for your return home or to new housing. This is called a discharge plan and will help you as you transition to a home environment. It is important to ask questions and collect all the information available to you.
Topics in this section include:
What is a discharge plan?
A discharge plan is a roadmap you can use to prepare. Its purpose is to ease the transition to your next destination. It includes information regarding:
- Any follow up appointments
- Medication and prescriptions
- Special equipment that might be needed
- Specific care instructions
- Therapies that may be required post-discharge
- Things to avoid during recovery/recuperation
By creating a comprehensive plan, you’ll have all the information you need in advance of the discharge day.
Making a discharge plan
The doctor(s) or nurses will speak with you and your family/loved ones about when they expect you to be ready to leave. This is generally done a few days in advance of the actual date. This may change as physical healing progresses. Many hospitals and rehabilitation centres have a discharge planning team that will give you as much notice and assistance as possible when coordinating your departure. It’s important to note that depending on your area and the hospital, there may be different resources available.
Start planning as early as possible for your discharge. Include caregivers and family members, and have honest discussions about your needs, wants, and capabilities. Request a team meeting at the hospital: it’s the best way to get everyone in the same room to discuss progress and discharge plans. During a lengthy hospital stay these meetings can occur more than once. Once you’ve established who will be a part of the discharge planning process, you’re ready to make your plan.
- Write everything down
- The first thing you should do is have a pen and paper with you at every appointment. Any instructions for care, rehabilitation information, and general notes should be either written down by you or provided to you in writing. Having this written transcript of instructions and notes will ensure you don’t forget or miss anything. You should also write down questions you have for the healthcare team to make sure you get the answers you need. Keep all these papers in a binder or folder that is clearly labeled and secure.
- Identify all your care needs
- You may have lifestyle changes that will affect your needs related to your health and overall well-being after your injury. This could include but is not limited to:
- Bathing and hygiene
- Emotional and mental health care
- Ongoing rehabilitation appointments
- Other forms of personal care like cooking, cleaning, etc.
- Physical care
These needs will be initially identified by the healthcare team based on their assessment of you. While there may be additional changes as recovery progresses, ongoing assessments can help determine what kinds of supports are needed.
It’s important to be honest about how you’re feeling and understand that accepting help is essential for both you and caregivers/family. They want to make sure you are safe and give you the support you need to help throughout your stages of recovery/ rehabilitation.
- Determine where you are going to live
- There are a few different places you could go after leaving the hospital:
- Your home
- A relative’s home
- A rehabilitation centre
- A long-term care home
Before you leave the hospital, you’ll have to work with the discharge team and your family to answer these questions:
- What challenges – physical, cognitive, emotional, or behavioural – will you have after the hospital? These will be identified in the previous step
- Are you able to live alone?
- Are you able to live with a family member or caregiver? If so, is there someone that can provide the care you need (i.e. a professional caregiver or family member)?
- How much and what type of rehabilitation do you need, and how are you going to get it?
- Could there be any risk to others (i.e. kids or spouse) if you do return home?
- If a long-term care home is the best option, when are you able to move in?
- If your bed isn’t ready in long-term care, where will you go in the meantime?
The answers will help decide where you will go immediately after the hospital or rehabilitation centre. This is an essential part of long-term care planning.
- Changes to the home environment
- If you’re returning to a home, it is important that the house/apartment is suited for your needs. This could mean something as simple as adding labels to things to help with memory to more complex renovations to accommodate for mobility.
It can be difficult to know what changes to make and which changes will be beneficial. An occupational therapist can help set up the home environment for you using what’s called a Home Safety Assessment and continue to work with you on activities of daily living (ADLs). An occupational therapist will perform a functional assessment of you, your family and the environment. They identify impairments and environmental barriers and create a treatment plan designed specifically for the individual with the brain injury. Not only can an occupational therapist improve the home environment, but they can continue to work with you on setting personal goals, improving skills, and increasing independence.
Local brain injury associations have support and services in place to help people with brain injury and their caregivers through these transitions. Find your local brain injury association
- Many individuals suffer mobility issues or are unable to drive after a brain injury. Most provinces/territories have accessible taxis or public transit options if the person with the brain injury needs extra room/assistance. This is information the hospital should be able to provide to you. You can also look into conversions to an existing vehicle or purchasing an accessible vehicle.
Once you begin to consider returning to driving, you will need to undergo assessment and training. More information about returning to driving
Public transportation is an option if available in your area. You may want to take into consideration some of the cognitive changes you are experiencing before venturing out on your own. Some people have new challenges with orientation, depth perception, and short-term memory which can make buses, subways, and trains dangerous without proper supports. You can prepare yourself by carrying a bus schedule or asking someone to go with you.
- Find out who to contact if you need something after discharge
- If you require information or assistance after you are discharged, ask the hospital team who you would speak with while you’re making your plan. Not every medical centre has a designated person to handle these calls, but they may be able to help you find a contact that can answer questions if you need something after discharge. Make sure to write down the name and contact information for the person the hospital says you can call. Your family doctor will also play a key role in monitoring recovery after discharge and will be able to help as you navigate rehabilitation.
What should I expect after returning home?
You need to prepare yourself for the fact that things will not go back to the way they were prior to the injury. You may experience many symptoms and changes connected to your brain injury that will affect how you interact with your family, community, and environment. A few examples include:
- Being unable to make choices when it comes to things like food or activities
- Changes in personality and behaviours
- Forgetting where things are located
- Needing help to navigate from room to room
You may be more focused on physical healing and getting back to how things were: but it’s important to understand that brain injury recovery can take a long time. Medications may help with symptoms, but they aren’t ‘cures. While some effects of brain injury get better over time, in many cases there is a permanent change. Recovery will be life-long and managing the effects of brain injury will become part of your ‘new normal’. Learn more about finding your new normal
As part of your discharge planning, take some time and ask yourself: “what is my life going to look like at home?” If you have concerns or need help talking through some of those changes, ask the hospital team about supports available to you. You can also reach out to local brain injury associations – they will be able to offer you more local resources and information.
There are some actions you and family members can take to make the transition home easier.
- Create a daily schedule and routine
- Having a daily routine and schedule gives you a sense of order and takes the guesswork out what’s going to happen each day. This reduces stress and anxiety, which can make activities of daily living (ADLs) harder. This schedule can be written down each day (or made a week in advance) and posted in a place that you can easily see.
- Set goals
- Goals are designed to help people stay motivated and focused, and they will do the same for you. You can set goals for your home activities and for your rehabilitation. Remember to break your goals into small increments – if you set a goal that is too big or too far away, you may get discouraged. You can consult your rehabilitation and medical team about identifying and setting goals. They can also help you work step by step towards those goals.
- Focus on healthy living
- One of the most frustrating things about brain injury is that a lot of the effects are outside a person’s control. But there are things you can control – specifically, living as healthy a lifestyle as possible. This includes:
- Eating well. Learn more about nutrition and brain injury
- Practicing good sleep hygiene. Learn more about sleep after brain injury
- Exercising and doing rehabilitation activities
- Be patient with yourself
- The most important part of returning home is to be patient with yourself. You are going to be facing a lot of new challenges, and there will be things you won’t be able to do – at least right away. While this is stressful and frustrating, try to give yourself a break. Find little wins you can celebrate and practice positive thinking.
Disclaimer: There is no shortage of web-based online medical diagnostic tools, self-help or support groups, or sites that make unsubstantiated claims around diagnosis, treatment and recovery. Please note these sources may not be evidence-based, regulated or moderated properly and it is encouraged for individuals to seek advice and recommendations regarding diagnosis, treatment, and symptom management from a regulated healthcare professional such as a physician or nurse practitioner. Individuals should be cautioned about sites that make any of the following statements or claims that:
- The product or service promises a quick fix
- Sound too good to be true
- Are dramatic or sweeping and are not supported by reputable medical and scientific organizations.
- Use of terminology such as “research is currently underway” or “preliminary research results” which indicate there is no current research.
- The results or recommendations of a product or treatment are based on a single or small number of case studies and has not been peer-reviewed by external experts
- Use of testimonials from celebrities or previous clients/patients that are anecdotal and not evidence-based
Always proceed with caution and with the advice of your medical team.