When an elderly client is discharged home following a long hospitalization, it is essential for the nurse to initiate referrals to community resources that can support the client’s ongoing care and promote their well-being. The following resources are particularly important:
- Home Health Care Services: Referral to a home health care agency can provide nursing care, physical therapy, occupational therapy, and other services in the comfort of the client’s home. Home health services help manage chronic conditions, monitor recovery, and prevent readmission to the hospital (Harris-Kojetin et al., 2019).
- Meals on Wheels: This program delivers nutritious meals to elderly individuals who may have difficulty preparing their own food. Proper nutrition is vital for recovery and maintaining health, especially after a prolonged hospitalization (Thomas & Mor, 2013).
- Transportation Services: Many elderly clients may require assistance with transportation to attend follow-up appointments, pick up medications, or run errands. Referral to a community transportation service helps the client maintain their independence and adhere to their healthcare regimen (Lynott & Figueiredo, 2011).
- Adult Day Care Programs: These programs offer social interaction, activities, and supervision during the day, which can be particularly beneficial for elderly clients who live alone or have limited social support (Fields et al., 2018).
- Medication Management Programs: Community-based programs can assist the client in managing their medications, including setting up pill organizers, providing reminders, and monitoring for potential side effects or interactions (Gillespie, Mörlin, Hammarlund-Udenaes, & Hedström, 2012).
- Social Services: A referral to a social worker can connect the client with various benefits and services, such as financial assistance, housing support, and caregiver respite (Benjamin & Matthias, 2011).