Discharge Planning

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KEY POINTS

• Discharge planning includes learning what care you will need after you leave the hospital, deciding whether you should go home or to a facility for a while, and helping you get the services and equipment to meet your needs.
• Discharge planning involves you, your family, your healthcare provider, physical therapists, dietitians, pharmacists, nurses, and social workers.
• The discharge planning department of the hospital may also be called case management, social service, or patient-family services.

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What is discharge planning?

Discharge planning helps you prepare to leave the hospital. It involves talking about:

• When you may be able to leave the hospital
• What care, treatment, or help you will need after you leave
• Whether your needs can be met at home or if you need to stay in a skilled nursing or rehabilitation facility for a while

Discharge planning also involves connecting you with the community resources and helping you get equipment that you or your family will need.

Who is involved in discharge planning?

Many people are involved in discharge planning. These include your healthcare provider, physical therapists, dietitians, pharmacists, and nurses. Your healthcare team will teach you about:

• Your condition or your disease
• How to take your medicines and what they do, on a written list
• Your care at home, such as
  • Changing a dressing
  • Giving yourself a shot
  • Your activity level
  • Your diet
  • What symptoms or problems you should watch for and what to do if you have them

Nurses or social workers (sometimes called discharge planners or case managers) may visit you in the hospital to discuss services you will need when you leave the hospital. They can arrange for after-hospital services such as home care, home-delivered meals, or special equipment. They can help you check with the hospital, your insurer, or Medicare to find out what services may be covered and what you may need to pay. Your family may be a part of these discussions.

You and your family are very important in this process. Your role is to:

• Ask questions.
• Tell the staff what you need.
• Tell the staff if you don't think that you will be able to care for yourself, or if you don't have a family member or friend who can care for you.

After you go home, the discharge planning staff can still be a good resource. This department of the hospital may also be called case management, social service, or patient-family services. Call them if you have questions or concerns.

Where else can I go for help?

For information on community resources, call a local home care agency in your area. You can search for these agencies online or in the Yellow Pages under "nursing" or "home care." You can also call the local senior center or the Area Agency on Aging. To find your local Area Agency on Aging, call the national Eldercare Locator at 800-677-1116.