Discharge Planning: A Guide to a Smoother Transition

Posted by: The Bristal

Discharge PlanningIf you or a senior loved one are in the hospital or are preparing for a scheduled surgery, planning for discharge is a vital part of the recovery process. Utilizing the right resources for follow-up care can be especially important in helping prevent older adults from being readmitted to the hospital.

Good discharge planning can help patients make a smoother transition to the next step of their recovery. Failing to plan can have the opposite effect. One study found that, on discharge from the hospital, 30% of patients have at least one medication discrepancy. Additional research shows on average, 19.6% of Medicare fee-for-service beneficiaries discharged from the hospital are readmitted within 30 days and 34% are readmitted within 90 days.

What is Discharge Planning?

Depending upon the health care system, discharge planning usually begins on the day of admission or even before if a surgery is planned ahead of time.


According to the National Family Caregiver Alliance, there are six steps involved in the discharge planning process:

1. Evaluation of the patient by qualified personnel

2. Discussion with the patient or his representative

3. Planning for homecoming or transfer to another care facility

4. Determining if caregiver training or other support is needed

5. Referrals to home care agency and/or appropriate support organizations in the community

6. Arranging for follow-up appointments or tests

What is a Care Coordinator?

Most hospitals have teams of discharge planners, nurse case managers or social workers that help patients plan for the next step of their recovery. While the title may be different depending upon the hospital, these care coordinators help the patient and their family caregiver plan for a smooth transition to the next step in their recovery. They can act as the liaison between a skilled nursing facility and the rehab center, or help track down specialty equipment that the patient might need if being discharged to their home.

The Role of the Caregiver in Discharge Planning

Discharge Planning

You might be called upon to provide insight.

If you are a caregiver for a senior who is in the hospital or for a loved one that lives with a disability, you might be called upon to help provide information and insight during the discharge planning process including:

• The discharge planner or care coordinator might need your help understanding what an aging loved one with Alzheimer’s can still do independently and what they will need help with during recovery.

• If your senior family member has a vision or hearing impairment that makes communication more difficult, you might be called upon to help provide medical history and other important information needed for your loved one’s recovery.

• With the patient’s permission, caregivers can also participate in the selection of home health care or rehab providers, and attend any care conferences the hospital organizes to discuss next steps.

Post-acute Care Options under Medicare

Depending upon your situation or that of your senior loved one, the next step in recovery can involve discharge to a short-term rehab center, going home with the support of home health care or utilizing an outpatient rehab center. For Medicare patients, at least a portion of the costs for these services will be covered.

• Short-term Rehab Center: If a patient has been hospitalized at an inpatient level of care for three nights and their physician recommends a short-term rehab center, Medicare will pay for the first 20 days of care. For days 21 through 100, the patient will be responsible for a co-pay. Medicare does not pay for more than 100 days.

• Home Health Care: Some patients opt to return home and use a home health care agency for skilled nursing and therapy services. If the patient is considered homebound as certified by their physician, Medicare will pay for all of the home health services. The patient will be required to pay 20% of any necessary medical equipment.

• Outpatient Rehab Centers: Patients who choose to return home after a hospital stay and aren’t considered homebound and entitled to home health care, can elect to receive outpatient therapy. After you pay your Medicare Part B deductible for the year, Medicare will pay for 80% of your outpatient therapy services capping at $1,920 for physical therapy and speech-language pathology services combined and an additional $1,920 for occupational therapy.

For more information on Medicare coverage click here.

Asking the Right Questions during Discharge Planning

When you or the senior you are caring for is nearing the day of their discharge from the hospital, you will probably have many questions about what to expect next. Keep a list so you can be sure to have all of your concerns addressed before you leave the hospital.

Make sure your list of questions includes:

• An indication of how long to expect the recovery to last

• What to look for that might indicate a problem

• Who to call if questions or concerns come up after discharge

• When and who will review discharge instructions with you

For caregivers, make sure you are clear about:

• Any wound care or dressing changes you need to learn how to do

• What physician follow-up appointments you will need to schedule

• Contact information for specialists involved in your loved one’s care at the hospital

• The medication schedule and dosages

The bottom line is that advocating for your own care needs or those of a senior loved one, and planning ahead can help make for a better recovery and a smoother transition back home.


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