A trip to the hospital can be stressful and intimidating. As a family member, you are focused on your loved one’s medical treatment and so is the hospital staff. What happens when your relative leaves the hospital may not be on your mind, but it should be. How the discharge or transition from the hospital occurs is critical to the health and well-being of your loved one, and to their continued independence and quality of life.
As a caregiver, you are an essential part of the discharge planning process. The more you know about and understand the process, the better able you are to advocate for the patient and for yourself.
What is discharge planning?
Medicare defines discharge planning as “a process used to decide what a patient needs for a smooth move from one level of care to another.” Ideally, discharge planning is done by a team that includes the patient, family caregiver(s), the physician, and the hospital discharge planner (nurse or social worker).
In general, the basics of a discharge plan are:
• Evaluation of the patient by qualified personnel to determine post-hospital care needs;
• Discussion with the patient or his representative to assess the pre-hospitalization situation and access to family and other supports;
• Planning for homecoming or transfer to another care facility, e.g., rehabilitation center, skilled nursing, assisted living, or nursing home;
• Determining what caregiver training or other support is needed;
• Referrals to in-home or community-based services, e.g., home health care, adult day services, or case management; and
• Arranging for follow-up appointments or tests.
What can you do?
It is critical for you, as the caregiver, to know who the discharge planner is and to speak to that person early in the process. In addition, while your loved one is in the hospital, keep a notebook with all the names and contact information for those providing care and discharge planning. “Your Guide to Discharge Planning,” published by the Centers for Medicare and Medicaid Services, includes a useful checklist of suggested questions. It’s available at the website www.medicare.gov/publications/pubs/pdf/11376.pdf or by calling 1-800-MEDICARE. Be sure to keep all care instructions and referral information in your notebook.
What should the discharge plan include?
The discharge process and plan should address the following items:
• Your loved one’s condition and any likely problems or changes that could occur at home;
• A determination of Medicare or insurance eligibility for the recommended discharge services, e.g., rehabilitation, skilled nursing, home health, adult day services;
• Establishment of home care services, and necessary equipment rentals or home modifications;
• Referral to community-based services, e.g., adult day services or case management to help coordinate and manage post-discharge services;
• A review of all medications taken prior to admission and all the medications prescribed to be taken post discharge to ensure no duplications, omissions or harmful side effects;
• A complete written medication list with dosage instructions;
• The teaching and practicing of specific patient care procedures;
• Dates and times of follow-up appointments;
• A 24-hour phone number for the caregiver to call to speak with a health care professional regarding any health and care-related concerns; and
• Transportation home.
What if you do not agree with the discharge date?
If you do not agree with your loved one’s discharge, you may appeal the discharge. Talk first with the physician and the discharge planner to express your concerns and to ask for a review of the decision. If that does not work, contact Medicare, Medicaid, or your insurance company to institute a formal appeal. Until a decision is rendered, the hospital cannot force you to take your loved one home or pay for continuing care. If your appeal is denied, however, you will be required to pay for the additional hospital care.
Finally, remember that hospital discharge planning is short term – it is not an exact forecast of the future for your loved one. Peace of mind comes from knowing what home- and community-based services are available and beneficial to you and your loved one, now and in the future.
For more information about discharge planning and referral to in-home and community-based services, call SeniorLine at LIFE Senior Services, (918) 664-9000 or (866) 664-9009 toll-free.
For additional information
“A Family Caregiver’s Guide to Hospital Discharge Planning,” by the National Alliance for Caregiving and the United Hospital Fund of New York; www.caregiving.org/pubs/brochures/familydischargeplanning.pdf.
“Planning for Your Discharge: A Checklist for Patients and Caregivers,” by CMS (Center for Medicare and Medicaid Services); www.medicare.gov/publications/pubs/pdf/11376.pdf or (800) MEDICARE toll-free.
“Discharge Planning: A Guide for Families and Caregivers” and “Strategies for Working with a Discharge Planner,” by Family Caregiver Alliance: National Center on Caregiving; www.caregiver.org or (800) 445-8106.