Discharge Planning and Decision Making
Discharge Planning
Discharge planning starts at admission. This may seem strange to you. It may feel too soon to think about such things since you don’t seem ready. It is important for staff to develop a plan early so that you are linked to the best resources as soon as possible.
Decision-Making
People who survive a stroke may not be able to make decisions about financial matters, healthcare needs or discharge planning. The nurse case manager and/or social worker may need to assist family in sorting through what can be complex systems.
Advance Medical Directives
These are legal forms that allow you to state your health care wishes in the event that you become unable to do so. These papers let others know about your health care wishes and can help guide care. They make it easier for doctors and family members to follow through with your health care wishes. There are two kinds of advance directives: the Durable Power of Attorney of Health Care and a Living Will.
Durable Power of Attorney for Health Care
This document allows you to name someone you know and trust to act on your behalf when you can no longer speak for yourself. This person, or health care agent, gives guidance to your health care team only when the patient is unable to do so. This form must be filled out by the patient when they are able to understand the information.
Living Will
The Living Will covers only “end of life” decisions when life-support machines and/or feeding tubes are being used. Unlike the Power of Attorney for Health Care it does not allow a person to choose someone to make healthcare decisions for them.
Guardianship
Guardianship of a person and estate may be needed for a patient who is unable to make decisions and has not completed a health care power of attorney form. The guardian will be able to handle health and/or financial matters. Temporary and/or permanent guardianship can be pursued as needed. The social worker can assist you with this process.
Disability and Insurance Resources
Private Disability Insurance
If a person is employed and has health insurance, there is the chance they may have also signed up for disability insurance through their employer. This can be confirmed by calling their Human Resources office.
Social Security
Disability benefits can also be obtained through Social Security. There are two types: SSI and SSDI. These can be applied for by contacting Social Security (800-772-1213). They will provide help to apply by phone. The hospital will be required to provide Social Security with medical information.
Medical Assistance (also known as Medicaid or Title 19)
This is health insurance for patients who meet certain requirements. Disabled patients often meet these requirements. One can apply for this program through the county Human Services Department.
The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.
Last Updated: 09/19/2012
Copyright © 09/19/2012 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#7427
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