Hospital Discharge Planning: A Caregiver’s Guide to Leaving the Hospital

When the loved one in your care ends up hospitalized, your focus tends to linger on the immediate: how they’re feeling, the care they’re receiving, and how soon you can leave. Truth be told, their doctors and nurses are focused on the same things. It’s usually not until you get home that you start realizing that you wish you had asked more questions, gotten clearer instructions, or written more down. To avoid those regrets, let’s talk about hospital discharge planning: what it is, how to do it, and why you should. Let’s dive in.

What is Hospital Discharge Planning?

Hospital discharge planning is preparing to “transition a patient from one level of care to the next.” (Source)

In most cases, discharge plans are essentially instructions for how to care for your loved one after they leave the hospital — either to head home or to a longer-term care facility. These instructions can be written to either the family in charge of care or subsequent care providers, depending on the situation.

Unfortunately, not all discharge plans are created equal, some are more thoughtfully curated than others, and some are not created at all. Note that if you’re preparing to leave the hospital, you may have to request one – they are not always offered.

A hospital discharge plan usually includes things like:

Where your loved one will be discharged to
The types of care they need
Who will provide that care
Instructions for outpatient care, which may include rehabilitation, future/further testing, any necessary follow-up appointments, and expected lifestyle modifications
A complete list of medications (including dosages and usage information, like foods/beverages/other medications to avoid while using the prescription)

All of this should be written in plain, non-medical jargon wording, making it easy to follow and understand.

Additionally, it is important to ensure the hospital care team has placed orders for any home health, outpatient care, or durable medical equipment before your loved one leaves the hospital.

Why Discharge Plans Matter

The average American is living longer, meaning that more elderly adults are living with chronic diseases and more frequent, or more likely instances of hospitalization. (Source) Costs for hospitalizations have gone up, care professionals are often understaffed, and more pressure is placed on the family and friends of older adults to provide care at home to reduce all of the aforementioned resource strains.

How these matters are handled both in the hospital and at home directly affects your loved one’s quality of life. Inadequate discharge planning can result in increased readmission rates and, as we touched on, a decreased quality of life. (Source)

Common post-discharge complications include:

Harmful drug events (poor dosing, mixed medications, uncommunicated changes to existing medication prescriptions, etc.)
Hospital-acquired infections
Procedural complications.

A lot of these problems can be resolved with discharge planning.

If you feel that your loved one is not ready to be discharged you can submit a Medicare appeal, to have your loved ones needs assessed to determine if they are appropriate to be discharged and to help ensure a safe discharge is planned for your loved one. You can ask to speak to a case manager, or call Medicare directly to file an appeal: Fast appeals | Medicare

The Bottom Line for Caregivers

You as a caregiver are likely often tasked with responsibilities you received inadequate at best, or completely none, at worst – training to handle. These discharge plans are a great place to get answers that make you more comfortable with any new ones before you’re responsible for handling them on your own at home.

How to Get a Discharge Plan

To get a good discharge plan, the key word to focus on is collaboration. In most cases, your loved one has a hospital/emergency care team, a primary care team (including their PCP), you as a caregiver, the loved one in question, specialists they need, rehabilitation facility staff, and potentially live-in nurses or living facility care practitioners that may all need involvement for successful discharge plan execution.

To get a good discharge plan, it’s important to:

Participate in conversations. Actively engage with the hospital healthcare team by asking questions and openly discussing your concerns. Any disconnect between the information given by a clinician and your understanding may cause further complications or hospital readmission that could have been avoided.
Ask for one. If the hospital doesn’t offer, take it upon yourself to ask for a discharge plan.
Double-check the details. Ensure the plan includes details about the diagnosis, prognosis, any new medications, changes to existing medications/dosages, any needed follow-up appointments, additional equipment if needed, and clear instructions for managing the condition at home.

Closing Thoughts

Hospitalization is scary, but the fear shouldn’t have to come home with you. That’s why discharge planning is an important piece of the care journey.

The California Caregiver Resource Center of Orange County is here to provide assistance and guidance to caregivers in Orange County, CA. If that sounds like you, we invite you to check out our library of resources to help you navigate this experience. Together, we can navigate the healthcare landscape and help you provide the best possible care for your loved one(s).