What Every Elder Must Know About Discharge Hospital Planning


Learn the hospital discharge planning process as mandated by the Federal Law or get an elder advocate to protect your rights.


When it comes to discharging elders to nursing homes from hospitals, the more you know about the discharge process, the safer you or your loved one will be.

To discharge planners (also known by the cleaner term, case mix managers) like the ones at Methodist Hospital in Brooklyn, it means little more than finding an empty bed in any nursing home (regardless of quality) within 50 miles of the hospital.

This blog post is not about the perils of poor discharge planning in hospitals. For that you can visit my website at www.myelder.com. This post outlines the process that must be followed by all hospitals according to Federal Law. YOU MUST KNOW THIS or hire an elder advocate to protect you.


Discharge planning involves:

  • Determining the appropriate post-hospital discharge destination for a patient
  • Identifying what the patient requires for a smooth and safe transition from the acute care hospital/ post-acute care facility to his or her discharge destination
  • Beginning the process of meeting the patient’s identified pre- and post-discharge needs.
  • When the discharge planning process is well executed and there are no unavoidable complications or unrelated illnesses or injuries, the patient may continue progressing toward the goals of his or her plan of care after discharge.


Discharge Planning

Medicare-participating acute care hospitals/post-acute care facilities must identify patients who need or have requested a discharge plan at an early stage of their hospitalization. The discharge planning process must be thorough, clear, comprehensive, and understood by acute care hospital/post-acute care facility staff as well as the patient and/or the patient’s representative. The physician may make the final decision on whether a discharge plan is necessary. If a physician requests a discharge plan, one must be developed, even if the interdisciplinary team determines that it is not necessary.

Depending on the patient’s needs, discharge planning may be completed by personnel in multiple disciplines who have specific expertise. You may designate discharge planning responsibilities to appropriate qualified personnel such as registered nurses, social workers, pharmacists, or other qualified workers, pharmacists, or other qualified personnel.

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These individuals should have:

  • Discharge planning experience;
  • Knowledge of social and physical factors that affect functional status at discharge;
  • Knowledge of appropriate community-based services, supports, and facilities that can meet the patient’s post-discharge clinical and social needs;
  • Knowledge of the patient’s unique medical and other service and support needs


Discharge Planning Process

Appropriate facilities and vendors are those that can meet the patient’s assessed needs on a post-discharge basis and comply with Federal and State health and safety standards.

The discharge planning process includes:

  • Implementing a complete, timely, and accurate discharge planning evaluation process, including identification of high risk criteria.
  • Maintaining a complete and accurate file of appropriate community-based services, supports, and facilities where the patient can be transferred or referred. These services, supports, and facilities and include Nursing Facility (NF) or Skilled Nursing Facility (SNF) care, long-term acute care, rehabilitation services, Home Health care, Hospice, or other appropriate care (such as home-based supports).
  • Coordinating the discharge planning evaluation among various disciplines responsible for patient care.
  • Unless you develop a discharge planning evaluation for every patient, you must have a process to notify patients, patients’ representatives, and attending physicians that they may request an evaluation. You must also convey that the discharge planning evaluation will be completed upon request. The discharge planning evaluation determines the patient’s continuing care needs after he or she leaves the acute care hospital/post-acute care facility setting. Appropriate qualified personnel must complete discharge planning evaluations.


Discharge Planning Documents

Discharge planning should result in a written document, a discharge plan. The discharge plan should be a comprehensive tool and should:

  • Identify where and how a patient will get care after discharge;
  • Identify what the patient and his or her support groups (family, friends, hired help) can do to facilitate recovery;
  • Identify the healthcare problems to watch out for;
  • List necessary medications;
  • Make arrangements for necessary equipment or supplies in preparation for activities of daily living;
  • Explain how to cope with and manage one’s illness;
  • Identify sources of coverage and help with costs attendant to care.


While a good discharge plan does not necessarily have to be formal or follow a particular format, it should be clear and concise. It should be known to all relevant care givers and family members. When developed in a care setting such as a hospital, skilled nursing facility, home health agency, or hospice, the discharge plan should be included in the patient’s medical record.

My Elder provides elder advocacy services to families. Talk to us about long-term planning, finding the right home for your loved ones, preventing crisis and abuse, and ensuring they receive the best care possible.