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Understanding Hospital Discharge Planning

Many older family members may have special needs that develop as a result of a health condition for which they have been hospitalized.  Some older individuals need daily care after being discharged from the hospital.  Families and caregivers need to be aware of these issues and prepared to provide coordinated care for their loved one after he or she leaves the hospital.

What is hospital discharge planning?
Hospital discharge planning is crucial to ensuring that your aging loved one receives the post-hospital care needed to regain his or her health.  According to the publication,  A Family Caregiver’s Guide to Hospital Discharge Planning, Medicare defines hospital discharge planning as “a process used to decide what a patient needs for a smooth move from one level of care to another.”  This care might involve a brief or permanent stay at a skilled nursing facility, hospice, or family member’s home.  Some patients might be able to return to their own homes immediately.  Discharge planning means exploring the options for post-hospital care and deciding which is right for the patient and his or her family.

Getting the hospital to help
The hospital is prepared to provide guidance to help families understand and plan for their loved one’s post-hospital care.  Since, in many instances, discharge does not mean that the patient is fully recovered, but rather well enough to recuperate outside of the hospital, the hospital can provide a list of support services, care providers, nursing homes, and can even help family members decide which option best meets the needs of their loved one and which has as little financial impact as possible on the family.

The hospital discharge planner
When an aging loved one has been admitted to the hospital or seen by emergency room staff, the hospital discharge planner will likely make contact with the family automatically.  The hospital is responsible for making sure that the patient is being released into the safest environment possible, so they have a vested interest in discussing post-hospital care with the family members.  A hospital discharge planner can be either a nurse, social worker, hospital administrator, or might be identified by a different title.  The discharge planner will gather information about the patient’s home situation and make recommendations for post-hospital care.

Challenging the hospital discharge
It is the hospital’s job to provide solid medical care to patients.  But no one knows your aging relative like you and the rest of the family.  You may notice that something is wrong that the hospital staff might not recognize.  Sometimes a patient is just not medically ready for release.  For this reason, family members have the right to challenge the timing of the release.  A Medicare patient must be given an information leaflet called "An Important Message from Medicare" which details the patient’s right to care.  If the family elects to challenge the discharge timing, the hospital must provide a written notice called a Hospital-Issued Notice of Noncoverage (HINN).  This notice will contain the number of a local Peer Review Organization (PRO) whose responsibility it is to review the case and make a decision.  The family must contact the PRO immediately in order for the appeal to be considered valid.

Medicare has developed a checklist to assist families in developing a hospital discharge plan.

 



     
  • Hospital discharge planning is a process used to decide what a patient needs for a smooth move from one level of care to another.
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  • Hospital discharge planning is not a long-term care plan.
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  • The hospital has an on-staff planner who is there to help families plan for a loved one’s post-hospital care