Tag Archives: hospital discharge planner

Aging Parents: Hospital Discharges


Hospital discharge planning is the process of developing a plan post hospitalization for an individual to receive appropriate services {think home health, rehab or nursing home}. The hospital by law must identify, at an early stage of hospitalization, all patients who are likely to suffer adverse health consequences upon discharge. For our purpose, this identification begins at the time of admission when your parent presents their Medicare card. The nuts and bolts list of what is required of the discharge plan process is very lengthy {dare I say boring} but what you need to know is this:

  •  The doctor following your parent in the hospital is the one driving the discharge time frame. If your primary care physician is not following in the hospital they cannot write orders regarding your treatment or hospital discharge.
  • That physician is very aware of the Medicare A guidelines in terms of billing and believe it or not their hands may be tied. This all relates to diagnostic related groups which you can read more about here…
  • If your hospital says to you: “I’m sorry but we’ve assessed your mother and believe she does not need a discharge plan” you can have your physician request one.
  • A discharge planner is responsible for arranging the services your parent will need at the time of discharge. Your discharge planner may be referred to as a care manager, social worker or registered nurse.
  • You have the right to appeal your discharge and there are very specific steps in place to do this. Speak with your physician, discharge planner or patient advocate for specifics.
  • The hospital indication that it’s time for discharge does not mean mom is ready to live at home independently but that the condition she was admitted for is stabilized and her time under Medicare A has come to an end.
  • Your hospital discharge planner will provide you with a list of available services i.e. home health agencies, skilled nursing facilities and can provide you with education but cannot give an opinion or recommend a specific organization.
  • Be open and honest with your discharge planner. If your dad was struggling at home before this hospital admission, he will probably need additional help {either at home, rehab or nursing home, companion care} at the time of discharge.
  • In order to receive skilled Medicare A services following the hospital admission, your mom or dad needs to be in the acute care setting for a minimum of 3 DAYS! This means that if discharge to skilled rehab happens on the 2nd day your parent will not receive inpatient Medicare A coverage for their rehab. Be aware, ask questions and advocate!

A discharge planner’s job is a pressure cooker type job with high expectations and huge case loads. I recommend that within 48 -72 hours of your parent being admitted to the hospital {depending on the situation: if it looks like a short term stay move quicker} YOU ask to speak with your discharge planner. The RN on the floor or someone at the nurses’ station should be able to provide you with the name of your discharge planner and how to get in contact with that person.

I’m happy to answer any questions you may have! Leave a comment…