Bannockburn Neighbors Assisting Neighbors (NAN): Post-Hospital Discharge Help

Hospitalization: When a Bannockburn Senior is hospitalized, that person or a friend or family member of the senior, can contact NAN and request assistance related to the hospitalization. This assistance may consist of discharge and returning home arrangements.

Discharge: A Senior may request that a volunteer be present during the discharge conference.  After returning home, NAN may arrange transportation, if needed, to follow-up medically - related appointments and for errands. A "Friendly Visitor" may be welcome post - hospitalization for company and conversation. If the follow-up discharge instructions require home health services, they should be set up by the hospital social worker.  If not, NAN may refer the patient to several agencies and/or other services. The person returning home may be reminded that NAN has health aids that can be borrowed, e.g. wheel chair, walker, cane, shower seat, toilet seat and other devices. To borrow equipment, contact Miriam Kelty.

Time Frame of Services: When a neighbor returns from a hospital stay, assistance is likely needed when or shortly after arriving at home.  Planning for help from NAN prior to discharge is encouraged. To request such assistance, call JoAnn Krecke (301 706-1384) or Miriam Kelty  (301 229-5639) or your Block Coordinator.

Note to the Patient and Family

Information of Admission: NAN is concerned when any of our neighbors is admitted to the hospital. If a patient wants NAN to be involved in discharge planning and to be given information about hospitalization or follow-up by the hospital staff, a NAN person needs to be informed and agree. In addition that person needs to be identified and given permission to receive information from healthcare staff under the HIPAA Privacy Rules. If the formal paperwork authorizing the sharing of personal information is not completed prior to or at hospital admission, the patient or the family can inform NAN directly. This can be done by calling JoAnn or Miriam or your Block Coordinator. If you do not talk with one of them directly, leave a message, which includes the Hospital, room number and, if known, the specific help needed. This second option means that the information will be shared by the patient or family rather than by hospital or other healthcare staff.

Discharge to Home: Discharge to Home: When patients are about to be discharged home, they may request a social worker or case manager to assist them with a Discharge Plan. The Plan may include referrals for services that the patient may need once discharged. Such services could include home care services for nursing follow-up and therapy services such as physical therapy and occupational therapy. Patients frequently receive prescriptions for medications and instructions to follow-up with their private physicians.

NAN Services: If NAN is notified, we can plan to provide a number of services at home. The services can be:  Transportation to follow-up medical appointments or for othet purposes; errands; meals; a "Friendly Visitor"; household chores or other assistance.. Call JoAnn Krecke at 301 706-1384 or Miriam Kelty at 301 229-5630 or your Block Coordinator.

Need of Home Services: If the discharge papers include a prescription for professional  home services, NAN will provide a list and contact number of these services for the family or patient to select. NAN can also make a referral to a Geriatric Care Manager. It may be necessary to adjust the homes to the changing abilities of the patient. NAN can make referrals to home modification specialists but does not endorse or partner with any particular company or individual. 

Patients and caregivers may find this Center for Medicare Services discharge planning checklist helpful