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Hospital Discharge Planning


Topic Overview

What is discharge planning?

Discharge planning helps to make sure that you leave the hospital safely and smoothly and get the right care after that.

This sounds simple, but it can be frustrating.

You might wonder why you are leaving. You might have questions about what will happen when you get home and what your family can do to help. You may worry about who's going to pay for your care.

You, the person who is caring for you, and your discharge planner work together to address your concerns in a discharge plan. Whether you go home, to a relative's home, to a rehabilitation facility, or to another health care setting, your plan outlines the care you need.

Get involved with your discharge planning. You—or your caregiver—can give the discharge planner important information about your daily activities. Tell your discharge planner what you and your caregiver can and can't do, and make your wishes known.

As soon as you enter the hospital, begin thinking about your discharge. To help you, try using a:

Hospital Discharge ChecklistClick here to view a form.(What is a PDF document?).

Who do you talk to about discharge planning, and what kind of information will you get?

One person at the hospital usually is in charge of discharge planning. This person could be an administrator, a social worker, a doctor, or a nurse. The title of this person may be different at your hospital. But if you ask for the "discharge planner," you'll get to the right person.

Besides working with the discharge planner, you may talk with your doctor or surgeon, a nurse, a counselor, a social worker, or a patient advocate. They all may have information that will help make leaving the hospital go smoothly.

Your discharge planner can tell you why you are going home or to another health care setting and why your care is changing. You will work together on:

  • What care and services you may need after you leave. This can include nursing, physical therapy, occupational therapy, or speech therapy. An agency may set up a program to check your blood pressure, pulse, oxygen saturation, or weight.
  • What equipment you may need, such as a walker or oxygen.
  • Whether or not you can get care at your home. You may need to go to another health care setting, such as a skilled nursing facility, a rehabilitation hospital, or an assisted living facility. Or family or friends may stay with you at your home, or you may stay with them.
  • How to best move you from the hospital to your home or to another health care setting.
  • Any other options you may have instead of leaving the hospital or changing your care.

When do you start your discharge planning?

Start your discharge planning as soon as you enter the hospital.

  • Ask who the discharge planner is, and ask to meet with him or her when you check into the hospital.
  • Ask if you don't understand something about discharge planning, your role in the planning, or the written plan.
  • Write down the name, position, and contact number of everyone involved in your discharge planning. Take notes of your talks and decisions.

You may not feel well enough to ask the questions and take the steps you need to create a discharge plan. You can ask a family member, a friend, or a patient advocate to help you. Try not to make decisions about your discharge when you feel stressed or under pressure.

Also think about who can help you when you go home. Ask your doctor or nurse how much help you may need and for how long. Can your partner, spouse, son, or daughter do this? A friend? Think about work or school schedules and other duties people may have.

What about insurance and Medicare?

Many people are surprised to hear that their insurance or Medicare won't pay for care they receive after they leave the hospital. Talk to your insurance company or Medicare. Your discharge planner, a hospital social worker, or a patient advocate also may be able to help with your concerns about payment.

You may disagree with your discharge plan. You may think that it's too early to leave the hospital or that you need another type of care. If this happens, talk to your discharge planner, doctor, and insurance company about other options. If you can't agree, ask if you can challenge the discharge plan and what the first steps are. Be sure to keep notes of all your conversations.

If you use Medicare, you have certain rights. Talk to your state health insurance program, or visit www.medicarerights.org.

What if you're dealing with other health care settings?

If you have been living in another health care setting, you'll have to talk with someone about leaving for your hospital stay and then coming back afterward. Find out what you'll have to do to get the same bed and room, and ask about any costs.

If you have been living at home but will need to go to another setting when you leave the hospital, the discharge planner can give you a list of options. You, a family member, or a friend will have to call around to see which one you prefer. Things to think about when choosing another setting include:

  • How you’ll receive your prescriptions, such as on-site or by mail order or delivery.
  • If there are any problems with using any medical equipment.
  • How easy it is for your family or caregiver to get to it and visit you.

What if you're going home?

Before you leave the hospital, talk to your nurse or other hospital staff about things you'll have to do at home. Get information in writing about:

  • Your medicines. Get a list of medicines and how you take them. Have your doctor highlight any new medicines or medicines that need to be stopped or changed since before your hospital stay.
  • When you need to see the doctor again and any follow-up tests you need.
  • How and when to change bandages and dressings.
  • How active you can be. This may include fall precautions and physical therapy.
  • What you can and can't eat.
  • Whether you need any special equipment or supplies, such as a walker or oxygen.
  • What to do if you have questions or if there is an emergency.

It's easy to think you can do everything, but it can be hard. If you feel you or your caregiver won't or can't do certain tasks, say so. Try to make other arrangements.

To help you plan what you'll need after leaving the hospital, use this:

Hospital Discharge ChecklistClick here to view a form.(What is a PDF document?).
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