Hospital Discharge

You or someone close to you falls, suffers a stroke, illness or other health event and is hospitalized. Only too soon the hospital nurse or social worker starts talking about discharge and suddenly, you need to make arrangements.

Five key steps to help ensure a safe and appropriate transition:

Step 1: Talk to the hospital discharge planner.

The hospital discharge department exists to assist with discharge planning; it is the hospital’s responsibility to see to it that the discharge is a safe one. A safe discharge is one where all the services needed for care are in place.


Step 2: Know the pros and cons of common options – nursing home or home care.

Nursing home: Skilled nursing facilities can offer a more intense level of care and therapy than is usually the case at home. A nursing facility provides skilled nursing care, therapy, medical equipment and personal care assistance, in addition to meals and activities.

Home care: There are people who prefer to return home. Services, such as home health care, which includes skilled nursing care, physical, occupational and speech therapy, or out-patient therapy, as well as other services and durable medical equipment, make a home discharge possible. However, you may also need to arrange for a caregiver or family member to assist with non-medical personal care and household chores.


Step 3: Advocate for a safe discharge.

Because hospital discharge staff are under pressure to make arrangements for many patients, it is important to advocate for yourself or your family member to make sure that the arrangements for a safe discharge are in place. A safe discharge is a Medicare requirement that applies to Medicare beneficiaries who have been admitted to a hospital. However, it is important to advocate for patients who were held for observation, as well as for those who were admitted (see box below for more).


Step 4: Ask the discharge planner and/or your physician to make arrangements for the services you need.

Institutional care: Sometimes, the skilled facility for rehabilitation is part of the hospital.  If not, the attending physician or the hospital discharge department will have recommendations for a skilled facility. Ask for this information and for the discharge planner to make arrangements for the transfer if you choose this option.

Transportation: Ask the discharge planner what transport will be needed to bring the person to the skilled facility or home and how that will be arranged. Follow up to be sure the arrangements are in place.

Services at home: Home health care, durable medical equipment and out-patient therapy require a physician’s order. Often the physician will choose the provider. Make sure that the discharge planner has arranged this.

Personal care services: The hospital will not arrange for personal care services but usually has a list of approved agencies that you can call. Some discharge planners will narrow the choice to three options. Ask them to do this.

Geriatric care management: A geriatric care manager can be very helpful if family is not available. A care manager can arrange, coordinate and oversee care. To find a professional geriatric care manager, consult the National Association of Professional Geriatric Care Managers website. Your discharge planner may also have a recommended list of care managers. Ask about this.


Step 5: Make your choice – safety now, optimization later.

Most likely you will not have time to research the best choice possible and should not feel guilty about that. However, it is important to make sure that you or the person in need of help is safe. Then, you can take the time to learn about additional options for care and make whatever adjustment or change is necessary.

Once you have made your choices, remember to gather all contact information so that you are able to follow up after discharge.

Admission vs. Observation

Not everyone who goes to a hospital is actually admitted. Some patients are kept for observation only. The distinction between admission and observation is important. If a patient is admitted and remains in the hospital three or more days, Medicare will cover the cost of a stay during rehabilitation in a skilled nursing facility, minus deductibles and co-pays, of course. Medicare will not cover the cost of room and board in skilled nursing facility if the three-day admission criteria has not been met.