What is Discharge Planning?

What is Discharge Planning?


 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.



Tips for Starting the Conversation – Advanced Health Care Directive

Tips for Starting the Conversation – Advanced Health Care Directive


An advanced health care directive—also called a living will—enables you to make choices regarding your health care and relieves family, friends, or your health care advocate of making these decisions.  Each state and/or medical care facility requires different documents.

It is important that you express your health care desires to anyone who will be involved in decisions regarding your care if/when you cannot speak for yourself:  These might include your spouse, son or daughter, siblings, a trusted friend—and definitely the person who has your health care power of attorney.   A copy of your advanced health care directive should be kept with your will and other important documents, and a copy should be given to your health care provider or medical facility.

Here are some guidelines to assist in having this discussion with family or friends who will be responsible for your health care.

-Open the conversation by asking: “If you could no longer speak for yourself and your condition is considered terminal, what would be your desires?  Would you want aggressive treatment extending your life or would you rather be kept comfortable?  Would you rather be in a nursing facility or at home?”  Getting them to talk about their desires will provide the opportunity for your to express your own wishes.

-Use a current event to open the conversation.  Example:  “I heard on the news about doctors keeping a man alive in a vegetative state for three years.  Would you want that?  I sure wouldn’t.  That is why I have expressed my wishes in this document…”

-Open the discussion by saying: “I know this isn’t easy to talk about, but if I can no longer express my wishes regarding my health care, here is what I want done….”

-Ask for their help by saying:  “While I was in the doctor’s office, I picked up this form called ‘Advanced Health Care Directive’.  Would you mind checking it over to see if I completed it correctly?

If you have difficulty talking about this subject, prepare a letter or video expressing your wishes.

What the Bible Says About Dementia

What the Bible Says About Dementia


 There are no specific passages concerning dementia in the Bible. The wisest man, Solomon, addressed issues of growing old and death which are applicable to any age-related or terminal illness  He admonished:

  “Remember your Creator in the days of your youth, before the days of trouble come and the years approach when you will say, “I find no pleasure in them” – before the sun and the light and the moon and the stars grow dark, and the clouds return after the rain’ when the keepers of the house tremble, and the strong men stoop, when the grinders cease because they are few and those looking through the windows grow dim; when the doors to the street are closes and the sound of grinding fades; when people rise up at the sound of birds, but all their songs grow faint; when people are afraid of heights and of dangers in the streets; when the almond tree blossoms and the grasshopper drags itself along and desire no longer is stirred. Then people go their eternal home and mourners go about the street. Remember him – before the silver cord is severed, and the golden bowl is broken; before the pitcher is shattered at the spring, and the wheel broken at the well, and the dust returns to the ground it came from and the spirit returns to God who gave it. ‘Meaningless! Meaningless!’ says the Teacher. ‘Everything is meaningless.’”

(Ecclesiastes 12:1-8)

Solomon acknowledged that, from a human perspective, life can sometimes seem meaningless because of its brevity and problems.  There are many challenges as one ages and grows increasingly closer to their appointed time to die.  In the face of these circumstances—and especially in the face of dementia related challenges—Solomon admonishes that we remember our Creator before these conditions arise so that we will have a tried and true refuge for difficult times.

Although no specific passages address dementia, a major key to coping with this and any other generative disease is to remember that no matter your circumstances, God’s character does not change. His promises still hold true. Your circumstances do not change His purposes for you.

God is actively working “all things” together for good.  If you don’t see any good in your circumstances, it is because He isn’t finished working yet, for “…we know that for those who love God all things work together for good, for those who are called according to His purpose” (Romans 8:28). For some people, one of those “all things” includes dementia.. God does not say that all things are good—as dementia certainly is not good in itself!  Rather, God says He works  good in all things.

As it has been said, “If you aren’t dead, you aren’t done.”  God still has a purpose for those suffering with dementia.  You may not understand the “why” of this disease, but you can know that God is still in control of your life.  You aren’t done with your earthly mission until God says you are done.

With dementia, you may become uncertain about who you are or confused by the people around you, but God knows you.  You are not and never will be forgotten.  God declared:  “Can a mother forget her baby?  But even if she forgets, I will never forget you” (Isaiah 49:15).  In verse 16, God declares that your name is written on the palm of His hand.  There is no way you will be forgotten!

You will not lose your salvation if your dementia causes you to forget God.  The people of Israel willfully chose to forget God, yet the Word confirms that He saved them for His name’s sake:

             They did not remember the abundance of [God’s] steadfast love…
Yet he saved them for his name’s sake, that he might make known his mighty power.

             (Psalm 106:7, 8)

Claim and continue to trust in these precious promises of  God:

“…My grace is sufficient for you, for My strength is made perfect in weakness.” Therefore most gladly I will rather boast in my infirmities, that the power of Christ may rest upon me. Therefore I take pleasure in infirmities, in reproaches, in needs, in persecutions, in distresses, for Christ’s sake. For when I am weak, then I am strong.

(2 Corinthians 12:9, NKJV)

 I am with you always, even unto the end of the world. (Matthew 28:20, NKJV)

Yet in all these things we are more than conquerors through Him who loved us. For I am persuaded that neither death nor life, nor angels nor principalities nor powers, nor things present nor things to come, nor height nor depth, nor any other created thing, shall be able to separate us from the love of God which is in Christ Jesus our Lord.  

(Romans 8:37-39, NKJV)

 Nothing will separate you from God—not even dementia!

When I fear my faith will fail, Christ will hold me fast;
When the tempter would prevail, He will hold me fast.
I could never keep my hold through life’s fearful path;
For my love is often cold; He must hold me fast.

Those He saves are His delight, Christ will hold me fast;
Precious in his holy sight, He will hold me fast.
He’ll not let my soul be lost; His promises shall last;
Bought by Him at such a cost, He will hold me fast.

For my life He bled and died, Christ will hold me fast;
Justice has been satisfied; He will hold me fast.
Raised with Him to endless life, He will hold me fast
‘Till our faith is turned to sight, When He comes at last!

Chorus:  He will hold me fast, He will hold me fast;
For my Savior loves me so, He will hold me fast.

Remember that when you feel you no longer have strength to hold on to Him physically, mentally, or spiritually–He will hold on to you.  He will hold you fast!