How To Manage a Hospital Discharge to Home

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How To Manage a Hospital Discharge to Home

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(Editor's Note: Today's guest blogger, Carol Marak, offers tips on how to manage a hospital discharge when your caree will be returning home. Look for a follow-up article next week on how to manage a hospital discharge when your caree will be transferred to a skilled nursing facility.)

hospital-207692_640The first time you manage your caree's hospital discharge you realize how chaotic and disorganized the health care system can be. The discharge process can be fraught with last-minute changes, too little information that arrives too late, and health care professionals who seem to have exactly 30 seconds to answer your questions.

To help you manage the chaos, we've put together tips to help restore some order when your caree is being discharged from the hospital to home:

1. Start the discharge process as soon as possible.
You'll want to start preparing for discharge almost immediately after your caree's admission. You may only learn of a discharge date the day before or even the day off the actual discharge. Know that whether or not your caree's insurance, including Medicare, will continue to pay will trigger the discharge. And, sometimes, that trigger will happen the night before the day the discharge planner calls to say, "We're discharging your mom this morning."

Keep in mind that the goal of the discharge planning process is to identify and prepare for your caree's anticipated health care needs once he returns home.

2. Ask, including:

  • about your caree’s condition, the diagnosis, any change in treatment plans and next steps for care.

  • to be included in team meetings about the discharge.

  • to be involved in any treatments or therapies that you will be managing at home. Make a video of how the staff performs the tasks--the video will come in handy when you are home trying to do the same task.

  • to be introduced to the discharge planner or social worker who will be managing your caree's discharge planning. Share your goal of having your caree return home.

  • for regular updates. When do they expect the discharge to happen? What needs to happen in order for the discharge date to be determined?


If you are uncomfortable or feel pressured during the discharge process, ask to speak to a hospital patient representative. The patient representative can advocate on your behalf.

3. Identify which family members or friends can help with care at home and include them in the conversation. If family member or friends will not help, it's best to know now. You'll be able to pursue alternative sources of help.

4. Discuss these five key areas with the medical team to prevent problems at home after the discharge:

  • Describe life at home for your caree, including routines. Share information about the home environment, support needed, your caree's dietary restrictions, and any limitations on activities. What adjustments will you and your caree need to make at home?

  • Review medications, especially because a hospitalization could mean new meds or a new med schedule. Use a reconciled medication list to discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.

  • Ask your caree's physician to identify any changes in your caree's condition that signal a potential problem. If the changes happen at home, what do you do? What change would require immediate medical attention?

  • Ask about test results. If test results are not available at discharge, find out when to expect results and who to call to obtain them.

  • Make follow-up appointments. Make sure you know what follow-up is needed.


5. Find out about programs or services that can help you once your caree returns home. Ask the discharge planner if your caree qualifies for any help at home through his insurance carrier, including Medicare. Help at home can include visits from a nurse, a therapist (physical, occupational and/or speech) and a home health aide. Will the insurance cover any equipment or devices that your caree will need?

You may want to note what help your caree will need once he returns home, including:

  • Bathing

  • Dressing

  • Eating

  • Personal hygiene like brushing teeth

  • Grooming

  • Toileting

  • Transfer from bed to chair, etc.

  • Mobility

  • Medication management

  • Medical equipment like IV, oxygen, infusion

  • Managing pain

  • Coordinating care with doctors or health care workers

  • Doctor's appointments

  • Transportation

  • Household chores

  • Meal preparation


Once you have an idea of the help your caree will need and what insurance benefits will provide, you can look to these community services and organizations for assistance to fill in the gaps not covered by insurance:

  • Home health agencies

  • Meals on Wheels

  • Personal emergency response system

  • Adult day care

  • Senior center


You also can search for programs in your community at www.benefitscheckup.org.

These resources offer information about the discharge planning process and support for you after your caree receives a diagnosis:

Be sure to voice any concerns you have at any point during the discharge process. You know your caree best.

What tips and suggestions would you add?

Carol Marak is a contributor for the senior living and health care market. She writes on tough topics that older adults and family caregivers face; chronic issues, senior health care and housing. She advocates preventative measures that promote healthy and fulfilling lifestyle options. Her work is found on AssistedLivingFacilities.org.

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