It is important for providers to understand the potential resident’s perspective during and even before the discharge planning process and what caregiving organization guidelines are communicating to the public at large.
All patients are assessed in terms of health, functional, and social care needs, at or before admission, and these needs are continually reviewed during the hospital stay.
This includes documentation and decision making to determine when it is appropriate and safe for a patient to leave the hospital, as well as establishing policies, procedures, and criteria for that discharge and establishing a discharge plan for every patient that is recorded in the patient’s record.

Rhoda Weiss, an international consultant, writer, and educator based in Santa Monica, Calif., says patients are typically educated on the projected length of their hospital stays and the plans for post-hospitalization before planned hospital stays or shortly after becoming a hospital patient for unplanned stays.
“Even if the patient does not need any post-acute care from a provider, that patient—whether discharged from a hospital, outpatient setting, or emergency department—still requires education, information, lifestyle hints, risk-lowering health skills, prevention techniques, and referrals,” she says.
Here is a sample of the kind of information potential residents are being told by caregiving organizations and what to expect before and during the discharge planning process.

Be Proactive

As soon as a loved one enters the hospital, ask the attending physician how long they expect the patient will remain there. Tell the physician and the hospital unit secretary a meeting with a discharge planner/case manager is needed as soon as possible, so arrangements can be made for whatever continued care is necessary. Discharge planners and case managers find their time consumed with patients who are leaving the hospital “that day.” By asking for a consult right away, caregivers and patients can become a partner in the discharge process.

Find Out About Insurance

The discharge planner can help find out what a loved one is entitled to under their insurance. Specific medical criteria must be met in order for a nursing facility stay to be covered. The same goes for coverage of various home health aides and durable medical equipment. Let the discharge planner make these calls, so a caregiver can concentrate on the more important decisions.
It is also important to talk to a discharge planner about whether or not ambulance transport is needed. Depending on the insurance, this service may or may not be covered.
Many families are shocked to receive a bill, which can run into the hundreds of dollars.

Share Information

Be prepared to inform the discharge planner about a loved one’s health history. In addition, the discharge planner will want to know about a loved one’s activities before the hospitalization in order to better assess what services and/or equipment that may be needed to help in caregiving.
Often, a patient will have more needs upon discharge from the hospital. For instance, before the hospitalization, he/she may have been able to stand and pivot during transfers. After the hospitalization, full assistance may be needed. If the house or apartment where a patient is headed to has narrow doorways or steep, curving stairways, a hospital bed or other durable medical equipment may not fit. Make sure discharge planners know about these barriers.

Home-based Agencies

Home health agencies offer a variety of services, including certified nurse assistants, licensed practical and registered nurses, physical therapists, occupational therapists, speech therapists, dietitians, and sitters.

Make A List

Put together a list of any skilled nursing (rehabilitation) facilities (SNFs) or home health care agencies used for previous stays, and discuss which ones worked and why. For many patients, discharge from the hospital does not mean an immediate trip home. Today, a SNF is an extension of the hospital and is often the next step in recovery. The discharge planner will provide a list of Medicare- and Medicaid-approved SNFs or home health agencies in the surrounding area. The planner will also contact the facilities to determine which ones have openings and/or available equipment and staff.

Do Research Immediately

Check out area facilities or agencies before the day of discharge so there is not a rush into making a decision. Talk to family members and friends, and arrange to tour several facilities while a loved one is still in the hospital. Have a backup choice in case the first pick is full.
Talk to a physician about who will be providing care at the facility. Many physicians don’t make rounds at nursing facilities, so a patient will most likely be seen by another physician while there. But, sometimes they do have connections to a SNF or other facility.
If a doctor does not visit a particular facility, this shouldn’t be a problem if it is a short-term placement. Some hospitals run their own SNFs within the hospital complex. The discharge planner will note if a hospital does and if these beds are available.
Keep in mind that before any transfer, the physician providing care in the hospital is responsible for preparing a discharge summary. The discharge summary should include a description of the hospital course of treatment, a list of medical problems and medications, and rehabilitation instructions. Ask the discharge planner for a copy of this document. Make sure to understand what is being asked and whether or not the care plan is doable.

Ask For Help

It is natural to feel a patient is being discharged before they are ready. Remember, hospital stays are much shorter than they used to be.
It is also likely that a patient will have special medical needs that will continue beyond the hospitalization. The discharge planner is there to help make all the necessary arrangements for transfer to a SNF, for the use of home health equipment, or for health aides.
The day someone enters the hospital is usually not the time to be thinking about discharge. But in this era when the hospital is viewed as just the first stop in the healing process, it’s never too early to begin planning for the next one.
Source: Rhoda Weiss and caregiving tips online