discharge planning process medicare rights

Creating Smooth Discharge Planning Transitions

For many patients, being in the hospital is like riding a bullet train. Zipping from room to room, procedure to procedure, being jabbed, jostled and poked, and then suddenly being told it’s time to disembark. Taking time now to understand the discharge planning process can help  ease stress and ensure you are aware of your patient rights. 

So It’s Time to Leave the Hospital, Now What?

by Jullie Gray, MSW, LICSW, CMC – Aging Life Care Association™ Member and Fellow of the Leadership Academy


Ideally, we’d like to think of hospitals as places of rest where we will get better, but these days, hospitals are very busy and often noisy places. It’s easy to feel fatigued, scared and confused by the whole hospitalization process.  Feeling overwhelmed starts as soon as your mom or dad walks through the hospital door, there are hundreds of rapid fire questions from the admission clerk, nurse, technicians and doctors. After the initial burst of activity, you and your parent will probably wait many long hours wondering about the results of her tests and what the final diagnosis will ultimately mean for the future.

Sometimes the most frightening part of the whole experience is when your mom is told it’s time to leave the hospital. She may still feel quite weak, unsure of how to manage her new medical problems and may worry about how she will cope back at home all alone. And you might feel a sense of unease about her discharge too; sensing that she isn’t quite herself, that something still might be terribly wrong. You may even worry that she doesn’t have enough or the right kind of help.

Caught off-guard or disagree with the discharge? Medicare beneficiaries have a right to appeal, but you’ll have to act fast. Read “Slowing Down Hospital Discharge Requires Fast Action”  from Kaiser Health News to learn more.

Although most people hope to be cured when they leave the hospital, realistically, when your mother is discharged, the difficult journey to recovery may only be starting. That’s because in today’s world, patients are leaving the hospital faster than ever before. Being discharged doesn’t mean your parent is well again, instead discharge indicates the attending physician has determined she is “medically stable” enough to leave the protective and expensive hospital setting.  But, because the process of healing is just beginning, older adults usually need more help at the time of discharge than before entering the hospital in the first place.

Role of the Discharge Planner

In the hospital, the person responsible for planning your parent’s discharge is called the “discharge planner”.  Discharge planners are employees of the hospital and are generally social workers or nurses. The discharge planner helps each patient move out of the hospital by setting up and coordinating necessary aftercare services before discharge occurs.

Insurance rules, financial pressures and the need to keep beds available for other patients drives the hospital team to plan early for discharge.  A well-designed discharge plan helps keep patients from waiting longer than necessary to transition through the healthcare system and ensures that patients are safely cared for during the next leg of their journey.

Derailments can happen

For most hospitals, the focus on discharge is very intense; almost as intense as finding out the reason your parent was admitted there in the first place – but that doesn’t mean things don’t occasionally go wrong when your parent leaves.

Patients and their loved ones often feel unprepared at the time of discharge. Studies show that older adults who are discharged from the hospital are frequently:

  • unprepared for their role in the next care setting;
  • confused about how to manage their condition;
  • unable to contact an appropriate health care practitioners for guidance; and,
  • left to carry out tasks their health care providers have left undone.

Whether your parent’s admission was planned or was due to an unexpected incident, it is helpful to make sure you are both prepared for the next stage of the journey.  At the time of discharge make certain your parent has

  • the newest prescription(s) in hand, knows what the medication is for, understands the new instructions and has reconciled the discharge medications with the previous list;
  • schedules a follow-up appointment with the physician, has a way to get to the appointment; and,
  • is given a list of signs and symptoms that constitute complications to her condition requiring immediate medical attention.

Any of these oversights can lead to serious problems and delayed recovery.

Help is just a phone call away

For families feeling overwhelmed by the discharge planning process, working with an Aging Life Care Manger™ can be a godsend. These highly trained professionals bring years of experience and work only for you (not the hospital or insurance company). They ease transitions by helping your family:

  • Set priorities
  • Review options
  • Make informed decisions
  • Implement practical solutions
  • Tie up loose ends

Aging Life Care Managers know the best resources in the community.  They can provide individualized recommendations for follow-up services, coordinate those services, and monitor your parent as she recovers to her full potential.  As your very own trusted adviser, your care manager works collaboratively with harried discharge planners who frequently have less time than they’d like to provide individualized attention.

Care managers also work closely with your parent’s medical providers to ensure that critical information is passed along through each transition so nothing falls through the cracks.

Advocating for the rights of older adults is a central role of all Aging Life Care Mangers.  If problems arise, your care manager will advocate on behalf of your family to make certain that discharge plans makes sense and meet your parent’s specific needs.

It can be a huge relief to have an expert in your corner looking out for your family’s interest. To find your own Aging Life Care Manager go to www.aginglifecare.org and search for a practitioner in your area.

About the author:  Jullie Gray is a Fellow of the Leadership Academy, and has over 30 years of experience in healthcare and aging. She is a Principal at Aging Wisdom in Seattle, WA. Jullie is the President of the National Academy of Certified Care Managers and the Past President of the Aging Life Care™ Association. Follow her on LinkedIn and Twitter @agingwisdom, or email her at jgray@agingwisdom.com. Aging Wisdom has a presence on Facebook – we invite you to like our page.

This blog is for informational purposes only and does not constitute, nor is it intended to be a substitute for, professional advice, diagnosis, or treatment. Information on this blog does not necessarily reflect official positions of the Aging Life Care Association™ and is provided “as is” without warranty. Always consult with a qualified professional with any particular questions you may have regarding your or a family member’s needs.

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