How to Manage Your Loved One’s Discharge from a Hospital or Rehabilitation Center

Steps for Planning the Discharge

Discharge planning should begin very soon after admission to a hospital or rehabilitation facility. To begin, meet the hospital medical and discharge planning teams assigned to your loved one and be sure they know to contact you to discuss discharge plans.

Take these steps to plan a successful discharge:

Meet your discharge planning team
Meet with the health care team to learn diagnosis and treatment plan
Understand the next level of care
Clarify insurance options and other financial plans
Choose the next care setting and providers
Attend the discharge meeting
Arrange transportation to the next level of care
Ensure a smooth transition to the next level of care

Meet Your Discharge Planning Team

As soon as possible after your loved one's admission, seek out the discharge planners assigned to your loved one and be sure they know you. Have them keep you in the loop with your loved one’s care and work with them to plan your loved one’s discharge.

Meet with the Health Care Team to Learn Diagnoses and Treatment Plans

When meeting with the nurse or doctor:

Ask about and understand test results and new diagnoses
Receive an updated medication list. Ask the doctor to explain changes from the pre-hospitalization medication list, and update your at-home medication list. (See our article on Medical Information Forms and how to Be Prepared for a Medical Emergency)
Ask about and understand the recommended next level of care

If there have been changes in medication and / or if your loved one takes several medications, consider meeting with a hospital pharmacist to understand medication instructions, precautions, interactions, and side effects

Understand the Next Level of Care

The next level of care is determined by your loved one’s functional ability as assessed by a hospital worker - usually during the first 24 hours after admission. Find out when this assessment is scheduled, and be present for it.

During the assessment:

Ensure that you and your loved one understand what is being assessed and why
Ensure that the assessor receives a realistic view of your loved one’s actual current functional ability
If you or your loved one have preferences about the setting or the provider for the next level of care, inform the assessor so these preferences are considered during the assessment
Ask the assessor for the conclusions of the assessment and the implications about the appropriate recovery setting

Care Possibilities After Discharge

After illness, injury, or surgery, various needs may be present and many care options are available - both inpatient and outpatient.

In addition to medical care, your loved one may now require non-medical assistance in many aspects of daily life, as discussed below.

Inpatient Medical Care and Therapy

Short term inpatient rehabilitation
Skilled Nursing Facility / Subacute rehabilitation facility
Acute rehabilitation hospital (intensive therapy)

Note: patients who can walk independently without standby assistance most likely will not meet guidelines for an inpatient acute rehab stay.
Patients do not need to stay in the hospital for 3 nights to qualify for coverage under original Medicare of an acute rehabilitation stay.
Patients need 2 out of 3 disciplines to qualify for an acute stay: Occupational therapy, Physical therapy and/or Speech therapy.

Outpatient Medical Care and Therapy

Short term rehabilitation at an outpatient rehabilitation center
Patients live at home and go to a rehabilitation center or therapy clinic for their therapy services.

Home-based therapy
Therapists provide services at home.

Home health care
Includes:

Wound care
Chronic disease management programs. Ask specifically if such programs exist for your loved one’s condition
“Transition to home” programs that follow and assist patients during the first 30 days after discharge

Palliative care
For patients with a serious illness, palliative care may be an option. Palliative care is medical care "focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family." Patients still receiving curative treatment can receive palliative care at the same time. To find palliative care doctors, ask for a referral from the specialist treating the serious illness or the primary care physician.

(Sources: Get Palliative Care's "What is Palliative Care?" & Stanford University School of Medicine's "National Consensus Project Definition of Palliative Care)

Hospice
For terminally ill patients choosing comfort measures but not curative care

Non-Medical Support Which May Now be Required

Medical equipment or home modification
Assistive devices: walkers, canes, wheelchairs
Personal Care: Help with for activities of daily living such as bathing, dressing, eating, toileting, and transferring
Support for Instrumental activities of daily living. Includes:

Long Term Residential Care

For patients who do not need therapy but cannot live independently. Includes various levels of care:

Assisted living - for activities of daily living and medication management
Skilled nursing care - for long term medical care
Memory care - for memory loss or cognitive impairment

Care Management

Care managers, like ours at Care is There Geriatric Care Management, organize all the different services that your loved one needs. Care managers:

Help identify needs in all areas of life
Recommend best practice solutions
Help choose service providers
Put services into place
Monitor the performance of service providers, trouble-shoot problems, and change providers when necessary
Visit your loved one frequently to identify problems and create solutions
Ensure your loved one attends follow-up medical appointments
Advocate during emergencies
Keep you informed

Daily Money Management

Daily Money Managers, like ours at Care is There, help your loved one handle financial matters:

Ensure that financial plans are developed
File insurance claims
Pay bills
Set up safe and appropriate banking arrangements
Manage mail and correspondence
Organize tax documents
Use best practices to help prevent fraud

Clarify Insurance Coverage and Other Financial Options

Determine your loved one’s insurance coverage for the services they will need:

Medicare requirements for coverage of care in a skilled nursing facility is addressed later in this article. Medicare coverage for other services are discussed in the articles linked to above.
Check your loved one’s own insurance for their specific coverage. Contact their insurance professional for guidance. If they don’t have one, consider engaging one now.
If your loved one has long term care insurance, this is a good time to review coverage and options
Some required services may not be covered by insurance. Meet with your financial planner to discuss options.

Choose the Next Care Setting and Providers

By law, hospitals must give patients a choice of the provider they will use for their rehabilitation, home health care, hospice, etc. Many hospitals own such services, however your loved one may benefit from using a different provider.

You can help your loved one choose a provider and work with the discharge planner and the provider to set up that referral and transition.

Discharge planners often choose providers based on availability. By arranging discharges in advance with the provider, you may be able to arrange a more orderly discharge to your loved one’s provider of choice.

Things to consider when choosing a provider:

Location - proximity to your loved one’s home and their loved ones
Providers your loved one has used and is comfortable with
Providers who offer additional services that your loved one may need later
Insurance coverage

For more information on choosing providers, see our articles on:

Attend The Discharge Meeting

Be present with your loved one at the discharge meeting. Work with the discharge planner to put your preferred providers in place for the next level of care, and be sure you understand all the discharge instructions

Arrange Transportation to the Next Level of Care

Ensure transportation to the next level of care is arranged, either by the hospital or by you.
Transportation may be by ambulance (most expensive), non-emergent medical transportation, transportation provided by the facility to which the patient is transferring, or private vehicle.
Determine whether the transportation can be covered by insurance or whether your loved one will need to pay for it privately.
Wait for the transportation to arrive, and comfort your loved one during the wait. Be sure they have meals, hydration, and medications if the wait is extensive.
Meet your loved one at the next level of care and help them settle in

Ensure A Smooth Transition To The Next Level Of Care

Arrange for your loved one to have fresh clothing and any other comforts as they are discharged
Ensure that your loved one receives meals and medications while they are awaiting their discharge, anticipating the length of the discharge / admission processes.
Be present during the actual discharge
Be present during the admission to the next level of care

How Care is There Can Help:

If you are a long distance caregiver or already busy with career and family responsibilities, you may not be able to coordinate your loved one’s discharge. Care is There can help. We can:

Be your family’s contact with the discharge planning team
Meet with the health care team to learn diagnoses and treatment plan
Understand the next level of care
Clarify insurance options and other financial plans
Help you and your love one choose the next care setting and providers
Attend the discharge meeting on your behalf
Arrange transportation to the next level of care
Ensure a smooth transition to the next level of care
Keep you informed

Next Steps

Can’t be with your loved one to manage their discharge from the hospital or rehabilitation center? We can help!

Contact Care is There today for a free consultation!

Central Virginia: 434.326.5323
Toll Free: 800.434.1633
Email: Info@CareisThere.com