Once you leave hospital, it is important you continue to get the right healthcare and support from the right people. Discharge planning aims to make sure this happens. It is the link between the treatment you had in hospital and the care you will need in the community once discharged. Show
What is hospital discharge planning?Discharge planning is the development of a personalised plan to ensure the smooth transition of a patient from a health organisation such as a hospital to wherever the patient is going next — it might be home, residential care, respite care, palliative care or somewhere else. Good discharge planning can avoid complications after discharge from hospital, avoid errors with medications and may help prevent a person from being readmitted to hospital later on. Who is involved in hospital discharge planning?Discharge planning should involve the patient, carer, family and any staff involved in the patient’s care. Usually there will be one person, such as a discharge planner, who coordinates the process. What is included in hospital discharge planning?Discharge planning involves taking into account things like:
Discharge planning should ensure that all the services you need to support you once you leave hospital are in place. This might include things like community support with medications, dressings, food or cleaning. It might include aids and appliances to help you stay in your own home, independently. In some cases, it is simple. For example, you might be expected to leave hospital in 2 days with certain medications, and you might be told to see your GP 2 days after you get home. But if you have a chronic disease or need plenty of ongoing care, it could be more complex. It might involve you, your GP, other healthcare professionals, family members and carers. All of these people should have a copy of the discharge plan, so that everyone knows what they need to do to ensure that you have continuing care. Where appropriate, other people or organisations should have a copy too. These could include a residential care facility, rehabilitation services or community services. When is hospital discharge planning done?Ideally, discharge planning starts as soon as you are admitted to hospital. And ideally, it also involves you and your family, as well as hospital staff. If you are going in for elective surgery, the discharge planning may occur before you go into hospital — so appropriate care can be organised in advance for when you get out. A discharge summary is one part of a discharge plan. It is a document prepared while you are in hospital, usually by your hospital doctor. It is generally an electronic document, known as an electronic discharge summary (eDS). The hospital should send it to other healthcare professionals involved in your care, such as your GP or sometimes a pharmacist or carer. It is important your GP gets a copy of this document so that they know why you were admitted to hospital, what care you received and how to continue to care for you. A copy of the electronic discharge summary will also be added to your ‘my Health Record, unless you have opted out of having one. You may also be given a paper copy of the summary when you leave hospital. The discharge summary will explain:
Tips for a safe hospital dischargeHere are some questions you could ask yourself before you are discharged from hospital:
If you can’t answer those questions, please ask your hospital doctors and nurses for more information. It is their responsibility to make sure you have it all. If you still don’t have everything you need, ask for a nursing supervisor. Find a healthcare service with healthdirect’s Service Finder tool or call 1800 022 222 (known as NURSE-ON-CALL in Victoria) for 24-hour health advice and information. ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist. Last reviewed: March 2022 A trip to the hospital can be an intimidating event for patients and their families. As a caregiver, you are focused completely on your family member or friend’s medical care, and so is the hospital staff. You might not be giving much thought to what will happen when your friend or family member leaves the hospital. Everything about this transition – whether the discharge is to home, a short-term rehabilitation (“rehab”) center, or a residential nursing facility – is critical to the health and well-being of the person you care for. Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care. Patients, family caregivers, and health care providers all are involved in maintaining a patient’s health after discharge. Yet, while it’s a significant part of the overall care plan, there is a surprising lack of consistency in both the quality and process of discharge planning across the health care system. This fact sheet offers information, tools, and resources to support you and the person you care for during this critical time, including:
But first, let’s cover a few legal topics that will be relevant to you as a caregiver. Legal Issues Affecting CaregiversHIPAA: The Health Insurance Portability and Accountability ActYou may have heard about HIPAA restrictions. HIPAA rules impact the sharing of information about patients in medical care. Although when the act was first initiated there was some confusion about how much information families and caregivers could receive about a patient’s medical situation, it is now clear that information must be shared.
Advance Health Care DirectivesThese documents clarify who will speak for patients if they cannot speak for themselves.
Caregiver Advise, Record, Enable (CARE) ActThe CARE Actis in place to ensure hospitals aren’t discharging patients without preparing family caregivers. With the CARE Act, hospitals must do three things:
The CARE Act has been signed into law in the majority of U.S. States as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. AARP (American Association of Retired Persons) championed this act and continues working toward making it a law in every state. AARP has a helpful printable fact sheet on the CARE Act: https://www.aarp.org/content/dam/aarp/ppi/2019/03/the-care-act-implementation-progress-and-promise.pdf. You can also download your free CARE Act wallet card: https://www.aarp.org/caregiving/local/info-2017/care-act-aarp-wallet-card.html?cmp=RDRCT-4e6ca682-20200402. Print one for you and one for the person you care for to keep in your wallets next to insurance cards, so information on the CARE Act is at your fingertips when you need it. Language and Translation ServicesYou and your friend or family member have the right to have an interpreter present – it’s important that language not be a barrier to clear communication.
Quality of CareIf you have concerns about the quality of care a hospital, rehab, or nursing facility provides, you have a right to speak up – while it’s happening as well as after being discharged.
You can find more guidance about how to complain and be heard on the website of the Agency for Healthcare Research and Quality: https://www.ahrq.gov/patients-consumers/patient-involvement/how-to-complain.html. Now let’s get back to preparing for discharge. What Is Discharge Planning?According to Medicare, discharge planning is a process that determines the kind of care a patient needs after leaving the hospital. Discharge plans should ensure a patient’s transition from the hospital to another medical facility or to their home is as safe and smooth as possible. Only a physician can authorize a patientʼs release from the hospital, but the actual process and preparation of discharge planning can be completed by a number of people. Some hospitals have a dedicated discharge planning manager on staff, but your point person could also be a social worker, nurse, or other hospital representative. Ideally, and especially for the complicated medical conditions, discharge planning is done with a team approach. In general, the basics of a discharge plan are:
The planning discussion will cover everything from the types of care that will be required to equipment needs, from diet and meal planning to medication administration. Even transportation and chores should be covered. Why Is Good Discharge Planning So Important?The main reason discharge planning is such a priority – not just for hospitals and care teams, but also the U.S. Centers for Medicare and Medicaid Services – is this: Effective discharge planning can decrease the chances the person you care for is readmitted to the hospital. A thoughtfully developed plan aids recovery, ensures medications are prescribed, and given correctly, and adequately prepares you to take over your friend or family member’s care – all of which contribute to care that reduces the chance of readmissions. The challenge: No single, consistent approachNot all hospitals are successful in this. Although both the American Medical Association and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) offer recommendations for discharge planning, there is no universally utilized system in US hospitals. What we do know is research indicates that excellent planning and good follow-up can:
The Caregiver’s Role in the Discharge ProcessThe discharge planner will look to you, the caregiver, for history and insights about your friend or family member. As their advocate, you are likely to play a central role, managing many vital tasks:
As discharge nears, things can feel rushed at the hospital; in that rush, it can be easy to forget what needs to be discussed. If you’re feeling hurried, it is reasonable to ask the discharge planning team to slow things down so nothing is overlooked. You may want to print out and bring this fact sheet with you to the hospital; if for some reason the discharge planning team doesn’t cover these subjects, you should feel comfortable raising them, yourself. Caregiver capabilities
Discharge to home: Finding the help you needListed below are common care responsibilities you may be handling for your friend or family member after they return home:
There is no single best path for lining up the help you will need. Patients and caregivers turn to many different sources for support.
A few notes about in-home help and finding the right fit:
Our fact sheet on hiring in-home help includes advice and resources to get you started: https://www.caregiver.org/resource/hiring-home-help/. Discharge to a FacilityIf the patient is being discharged to a rehab facility or nursing home, effective transition planning should do the following:
Selecting the right facility
Paying for Care After DischargeUnderstanding and navigating payment for after-hospital care needs:
What if You Feel It’s Too Early for Discharge?As their advocate, you have the right to appeal a decision to discharge your friend or family member from the hospital if you think it’s too early or if you think discharge to home is not safe.
Basic Questions for Caregivers to AskQuestions about the illness:
What kind of care is needed?
Questions when the person I care for is being discharged to the home: *
Questions about training:
Questions when discharge is to a rehab facility or nursing home:
For longer stays:
Questions about medications:
Questions about follow-up care: *
Questions about finding help in the community:
Questions about my needs as a caregiver: *
* Adapted with permission from www.nextstepincare.org, United Hospital Fund. This is a lot of information. Any advice for people new to all of this?We know it can feel overwhelming. Here are three steps to make it a bit more manageable:
Additional ResourcesFamily Caregiver Alliance Website: www.caregiver.org Email: FCA CareNav: https://fca.cacrc.org/login Caregiver Services by State https://www.caregiver.org/connecting-caregivers/services-by-state/ Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimer’s disease, stroke, ALS, head injury, Parkinson’s, and other debilitating brain disorders that strike adults. FCA Caregiver Resources A listing of all caregiver resources is available online at our website (https://www.caregiver.org/caregiver-resources/all-resources/). Other Organizations and LinksMedical/Nursing Task Tutorials for Family Caregivers Home Alone Alliance Initiative, AARP Next Step in Care www.nextstepincare.org Medicare’s Nursing Home Compare Medicare Rights Center Center for Medicare Advocacy “Hospital Discharge Planning” Aging Life Care Association National Eldercare Locator Caregiver Action Network American Association of Retired Persons (AARP) This information was prepared and reviewed by Family Caregiver Alliance. Sources for this information include The Official U.S. Site for Medicare (https://www.medicare.gov), the U.S. Department of Health and Human Services Health Information Privacy Site (https://hhs.gov/hipaa), the National Institutes of Health U.S. National Library of Medicine (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235049/), the American Association of Retired Persons (AARP) (https://www.aarp.org), and UpToDate.com (https://www.uptodate.com/contents/hospital-discharge-and-readmission). Edited and updated by Trish Doherty (http://trishdoherty.net). Revised August 2021. © Family Caregiver Alliance. All rights reserved. |