Helping you return home after hospitalisation

Editor: Mr Philippe Migliasso Senior Healthcare Executive and Administrator at the Monaco Gerontological Coordination Centre (CCGM).

The majority of elderly people who are hospitalised consider it an ordeal, for both themselves and those around them. The French National Authority for Health (HAS) , in collaboration with Conseil National des Professionnels de Gériatrie, emphasise in their report on the problem of hospitalisation that the elderly are up to sixty times more likely to develop functional disabilities during hospitalisation with one in six significantly increasing their level of dependency. To ensure elderly people return home to a safe and comfortable environment, whilst also enabling them to remain at home on a long-term basis, avoiding further hospitalisation, the Monaco Gerontological Coordination Centre team CCGM), in close collaboration with the RAINIER III Clinical Gerontology Centre team has for several years been implementing a procedure to support hospitalised patients and their families to avoid any gaps in support between the end of the hospital stay and the return home.

What to do if you or an elderly loved one is hospitalised

As soon as you are admitted to a care facility, you need to think about your discharge plan and follow it carefully.

You’re familiar with the CCGM and received a home help plan before your hospitalisation

Be sure to inform the CCGM of your hospitalisation. The CCGM team can then contact: The social services department of the facility where you are hospitalised; They will familiarise themselves with your situation, in particular the assistance plan you received prior to your hospitalisation (AVS - T.A. - R.A.D. - I.D.E. private - physio etc.) The care team at the Centre de Gérontologie Clinique Rainier III, if you are hospitalised in a gerontology ward. The medical team can then access your latest independent living assessment, which will be taken into consideration when your state of health reaches the point at which a discharge plan can be prepared.

You’re not known to the CCGM

In the first few days after hospitalisation, request a meeting with themedical and nursing team to discuss your future. This team can provide all the information you need to analyse the situation and help you prepare for the decisions you need to make.

What to do after the medical team has presented your discharge plan?

Your health has improved and you're ready to return home. Your contact is the social services department of the hospital. The medical and nursing team will have sent the social services department an independence score. and the information needed to assess your ability to carry out daily tasks (washing, shopping, preparing meals, calling the emergency services if necessary, etc.). The facility's social worker, who is the point of contact at the ward where you're hospitalised, will pass on this information to the CCGM to assess your needs and determine what action needs to be taken to meet them.

You're known to the CCGM and received a home help plan prior to your hospitalisation

If your needs are the same, the social services department will be able to reinstate existing support by informing the relevant services to continue their involvement. If your needs have increased, the CCGM will notify the social services department to expand their support and your social worker at the hospital will outline care plan options. Following this consultation, they will make a direct request to the service providers. The CCGM team will make a home visit a few days after you've returned, to assess your day-to-day needs, and discuss any difficulties you might be experiencing.

You’re not known to the CCGM

The CCGM will draw up a care plan based on the assessments made by the social services department to meet your primary needs (washing - shopping - meal preparation - help with treatment, etc.) Your social worker at the hospital will advise you of the proposed help, explain the care plan, and enlist the service providers. Once you return home, your contact will be the CCGM. . The team will reach out to you in the following days to offer an independent living assessment. It's necessary to wait a few days to be able to determine your needs.

Our solution to facilitate your return home

Help with returning home: the hospital discharge autonomy allowance package. If you are not in receipt of the autonomy allowance/strong> and you require care assistant services on a permanent basis to help you carry essential daily tasks after your return home, the CCGM has an option of paying for these services as part of a hospital discharge autonomy allowance package. This lump sum will meet all expenses usually covered by the autonomy allowance for a maximum period of 1 month, provided that the CCGM team carries out an independent living assessment at the patient's home and that the autonomy allowance application is submitted with a co-payment (ticket modérateur) This payment is subject to a cap and is activated after all essential needs have been determined. It is a one-off payment.