Hospital Discharge Planning

What is hospital discharge planning?

Discharge planning helps to make sure that you leave the hospital safely and smoothly and get the right care after that. In the days before you expect to leave the hospital, you'll meet with your discharge planner.

You, the person who is caring for you, and your discharge planner work together to address your concerns in a discharge plan. Whether you go home, to a relative's home, to a rehabilitation (rehab) facility, or to another healthcare setting, your plan outlines the care you need.

Your discharge planner can help you understand why you are going home or to another healthcare setting and why your care is changing. You will work together on:

• Understanding what all your discharge paperwork means.
• Knowing the signs of any problems and who you should contact.
• What care and services you may need after you leave. This can include nursing, physical therapy, occupational therapy, or speech therapy. A healthcare agency may set up regular visits from a home care provider, who can check things like your blood pressure, pulse, oxygen saturation, or weight.
• What equipment you may need (such as a hospital bed, walker, or oxygen) to have ready for you when you get home.
• Making sure your prescriptions are sent to and filled at the right pharmacy.
• Setting up your home to avoid falls. This may include clearing hallways, removing loose rugs, and picking items up off the floor. You can also use night-lights and cordless phones and put an adjustable guard rail on your bed.
• Whether or not you can get care at your home. You may need to go to another healthcare setting, such as a skilled nursing facility, a rehab hospital, or an assisted living facility. Or family or friends may stay with you at your home, or you may stay with them.
• How you'll get from the hospital to your home or to another healthcare setting.

Write down any questions you have about what will happen when you get home, what your family can do to help, or who's going to pay for your care.

What happens when you leave the hospital?

When it's time to leave the hospital, you'll follow your discharge plan.

Going home

Before you leave the hospital, talk to your care team and discharge planner about things you'll have to do at home. Get information in writing about:

• Your medicines. Get a list of medicines and how you take them. Have your doctor highlight any new medicines or medicines that need to be stopped or changed since before your hospital stay.
• When you need to see the doctor again and any follow-up tests you need.
• How and when to change your bandages.
• How active you can be. This may include physical therapy and taking steps to prevent falls.
• What you can and can't eat.
• What to do if you have questions or if there is an emergency.

Your discharge planner can help you arrange to get the supplies you’ll need at home. These may include:

• Supplies to prevent the spread of germs, such as hand sanitizer, gloves, and disinfectants. You may need to be especially careful with your personal waste.
• Medical equipment such as a pulse oximeter and blood pressure monitor. You may get some items from a medical equipment supplier.

It's easy to think you can do everything, but it can be hard. If you feel you or your caregiver won't or can't do certain tasks, say so. The discharge planner can help you make other arrangements.

Getting ready for a home care visit

When your home care provider visits you for the first time, here are some things you can have ready for them:

• Your discharge papers and any other medical documents from your hospital stay.
• The names and telephone numbers of your doctors, including specialists. Have both daytime and after-hours numbers handy.
• The phone numbers of family members and your emergency contacts.
• Your medicine bottles. Set them out where the provider can see them.

Make sure your provider has your phone number so they can call you to tell you they’re on their way. If you can’t get up, have someone there to open the door. And it’s a good idea to put your pets in a separate room so they won’t get in the way during the provider’s visit.

Going to another healthcare setting

If you have been living at home but will need to go to another setting when you leave the hospital, the discharge planner can give you a list of options. You, a family member, or a friend will have to call around to see which one you prefer. Things to think about when choosing another setting include:

• How you'll get your prescriptions, such as on-site or by mail order or delivery.
• If there are any problems with using any medical equipment.
• How easy it is for your family or caregiver to visit you there.

If you have been living in another healthcare setting—for example, a nursing home or a rehab hospital—you'll have to talk with someone at the facility about leaving for your hospital stay and then coming back afterward. They and the discharge planner can help you with a plan.

If you don't feel ready

Talk to your doctor about your concerns. Even though you may not feel strong enough to go home, your doctor can explain why you are ready to go home or to another healthcare setting.

If you still have concerns about going home, ask for help from the hospital's patient advocate.

How do you stay healthy after you leave the hospital?

Taking good care of yourself after you get home will help you recover and avoid problems. Here are some tips.

• Be sure to follow your doctor's instructions. They may include things like taking your medicine as prescribed, getting exercise, knowing what you can and can't eat, or knowing how to take care of an incision from surgery.
• Keep your home clean. Make sure you have plenty of hand sanitizer, gloves, and wound care bandages. Put disinfectant wipes and extra trash bags in every room. Have a trash can for things to throw away and a trash can for things that can be washed and reused.
• If you have a hospital bed in your home, place it near an electrical outlet. Get a waterproof mattress cover and XL twin sheets for it. Have extra pillows and foam bed wedges to use as needed.
• Put your phone near your bed, or wear a medical alert device. Then you can quickly call for help if you need it.
• For bladder or bowel control, use adult protective underwear and keep a bed pan close by. Also wear clothes that are easy to remove.
• Organize your medicine in a pillbox. Store it in a safe place. Use a calendar, alarm, or smartphone app to remind you to take it. If your medicine expires, take it to the pharmacy for proper disposal.
• Keep a calendar of all your appointments, deliveries, and dates to reorder supplies. When you think of questions, write them down in a notepad.
• Get clear plastic drawers to store your supplies and important papers in.
• Do activities you enjoy, such as puzzles, reading, or knitting. Or play a game with others. This will help keep your mind sharp.