Discharge Planning.  Discharge planning is a process to assure a smooth transition from one level of care to another.  Discharge from one facility to another of a different kind or a return home is usually determined by the patient’s condition and/or insurance coverage.

Discharge Authorization.   A doctor authorizes a patient’s release from a hospital or care facility, but discharge planning is most often done by a social worker, nurse, or case manager.

Discharge Inclusions.  Discharge planning should include:

-Evaluation of the patient by qualified personnel to determine need and/or readiness.

-Discussion with the patient or their health care representative.

-Planning for a return home or transfer to another care facility.

-Determining whether caregivers, training of family members, or other support is needed.

-Referrals to a home care agency and/or appropriate facility.

-Follow-up  appointments to evaluate the placement.

The discussion should include the physical condition of the patient; details of the types of care that will be needed; and whether discharge will be to a facility or their home.  Where the patient is placed depends upon whether or not the person’s condition is likely to improve, their physical and mental condition, and what daily activities they might need help with.  Preparations should also be made for medications; diet and meal preparation; transportation; and extra equipment might be needed–such as a wheelchair, commode, or oxygen.

The Importance Of Discharge Planning.  Discharge planning can decrease the chances that the patient is readmitted to the hospital, can establish the proper level of care, ensure medications are prescribed and given correctly, and train the caregiver to take over responsibilities.

The Caregiver’s Role. The discharge staff will not be familiar with all aspects of your circumstances. You may have physical, financial, or other limitations or obligations that affect your caregiving capabilities.   If some of the care is complicated, you may need training.

Home Care.  Listed below are responsibilities that must be handled when a patient returns home:

-Personal care: Bathing, eating, dressing, toileting.

-Daily care: Cooking, cleaning, laundry, shopping, finances.

-Health care: Medication management, doctor’s appointments,  therapy, wound treatment, injections, medical equipment, etc.

-Emotional care: Companionship, meaningful activities, conversation.

Community organizations can help with services such as transportation, meals, support groups, counseling, and a break from your care responsibilities. The discharge planner should be familiar with these community supports, but if not, your local senior center or a private case manager might be helpful.   If you need to hire paid in-home help, you can either hire an individual directly or go through a home care agency.

Facility Care.  If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarification of  the current state of the patient’s health and capabilities, a review of medications, and help to select the facility to which the patient is discharged.  Convenience is a factor—you need to be able to easily get to the facility—but the quality of care is also important, and you may have to sacrifice convenience for the sake of better care.

Paying For Care After Discharge.  Medicare does not pay for all services after a patient has been discharged from the hospital. However, if something is determined by the doctor to be “medically necessary,” you may be able to get coverage for certain skilled care or equipment. You will need to check directly with the hospital, your insurer, and Medicare to find out what is covered and what you will have to pay for.

Timing Of Discharge.  If you do not agree that your loved one is ready for discharge, you have the right to appeal the decision. Talk first with the physician and discharge planner and express your reservations. You may also need to contact Medicare, Medicaid, or your insurance company.


Questions about the illness.

-What can I expect?

-What should I watch for?

-Will we get home care and will a nurse or therapist come to our home to work with the patient? -Who pays for these services?

-How do I get advice about daily care, danger signs, and follow-up appointments?

 Questions about the care needed.



-Eating (diet restrictions, meal preparation)

-Personal hygiene



-Transfer (moving from bed to chair)

-Mobility (including walking)


-Managing symptoms (e.g., pain or nausea)

-Special equipment needed


-Household chores

-Taking care of finances

 Questions for discharge to a facility.

-How long is the patient expected to remain in the facility?

-Who will select the facility?

-Is there an online resources such as www.Medicare.gov to check the facility’s rating?

-Is the facility clean, well kept, quiet, a comfortable temperature?

-Does the facility have experience working with families of my culture/language?

-Does the staff speak our language?

-Is the food nutritious and/or culturally appropriate?

-Is the building safe (smoke detectors, sprinkler system, marked exits)?

-Is the location convenient? Do I have transportation to get there?

-How many staff are on duty at any given time?

-What is the staff turnover rate?

-Is there a social worker?

-Do residents have safe access to the outdoors?

-Are there special facilities/programs for dementia patients?

-Are there means for families to interact with staff?

-Is the staff welcoming to families?

 Questions for discharge home.

-Will someone come to the home to do an assessment to see if we need home modifications?

-Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra


-Are there stairs?

-Will we need a ramp, handrails, grab bars?

-Are hazards such as area rugs and electric cords out of the way?

-Will we need equipment such as a hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment?  Who pays for these items?

-Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?  Will insurance/Medicare/Medicaid pay for these?

-Do I need to hire additional help?

 Questions about training.

-Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment?

-Have I been trained in transfer skills and preventing falls?

-Who will train me?

-When will they train me?

-Can I begin the training prior to the patient’s return home?

Questions about medications.

-Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken?

-How will we know that the medicine is effective?

-Will this medicine interact with other medications?

-Is it prescription and nonprescription?

-Should this medicine be taken with food? Are there any foods or beverages to avoid?

-Can this medicine be chewed, crushed, dissolved, or mixed with other medicines?

-What possible side effects might be experienced with this medicine? At what point should I report these problems?

-Will the insurance program pay for this medicine?

-Is there a less expensive generic  alternative?

-Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling?

 Questions about follow-up appointments.

-What health professionals will the patient need to see?

-Have these appointments been made? If not, whom should I call to make these appointments?

-Where will the appointment be?

-What transportation arrangements need to be made?

-How will our regular doctor learn what happened in the hospital or rehab facility?

-Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?

Questions about finding help in the community.

-What agencies are available to help me with transportation or meals?

-What is adult day care and how do I find out about it?

-What public benefits is the patient eligible for?

-Where do I start to look for such assistance?

Questions about caregiver needs.

-What services will help me care for myself?

-Does my the patient require help at night?  If so, how will the caregiver get enough sleep?

-Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper?

-What medical conditions and limitations do I have that make providing this care difficult?

-Where can I find counseling and support groups?

-How can I get a leave from my job to provide care?

-How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs?


* Adapted with permission from www.nextstepincare.org, United Hospital Fund.