How Caregivers Can Help Guide the Process As the caregiver, you are an essential part of the discharge planning process. The better you understand the process, the better you will be able to advocate for the patient and for yourself. Meeting with the discharge planner early in the process should help ensure a smooth transition out of the hospital. Also, you may find it helpful in the longrun if you keep a notebook with all the names and contact information of people who are involved with the patient’s hospital care and discharge plan. This notebook is also a good place to keep all care instructions and referral information. “Your Discharge Planning Checklist,” published by the Centers for Medicare and Medicaid Services, is a useful tool for this process and is available online at www.medicare.gov or by calling (800) MEDICARE (633-4227). What if You Don’t Agree with the Discharge Date? If you don’t agree with your loved one’s planned date of discharge, you may appeal the discharge. Talk first with the physician and the discharge planner to express your concerns and request a review of the decision. If that does not work, contact Medicare, Medicaid or your insurance company to initiate a formal appeal. Until a decision is rendered, the hospital cannot force you to take your loved one home or pay for continuing care. However, legal steps may also be initiated by the hospital to develop an appropriate discharge resolution. Finally, remember that hospital discharge planning is short term. It is not an exact forecast of the future for your loved one. Peace of mind comes from knowing what home and community-based services are available to you and your loved one – now and in the future. Sources and Additional Information You can find additional discharge planning information, including “A Family Caregiver’s Guide to Hospital Discharge Planning” by the National Alliance for Caregiving and the United Hospital Fund of New York, at www.caregiving.org/resources/ care-recipient-health. For more Caregiver Support resources, see page 185.
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The Discharge Plan Should Include: •A n evaluation of the patient by qualified personnel to determine post-hospital care needs •A discussion with the patient and their caregiver(s) about the post-hospitalization care plan and access to family and other supports •A determination of Medicare or insurance eligibility for the recommended discharge services •A plan for homecoming or transfer to another care facility (e.g., rehabilitation center, skilled nursing, assisted living or nursing home) •R eferrals to in-home or community-based services (e.g., home healthcare, adult day health services or care management) •A discussion surrounding any possible problems or changes that could occur at home and a list of necessary equipment rentals or home modifications • A review of all medications taken prior to admission and all the medications prescribed to be taken post-discharge to avoid duplications, omissions or potential drug interactions •A complete written medication list with dosage instructions • Instructions for specific patient-care procedures •A list of dates and times of follow-up appointments •A list of any potential warning signs that require immediate actions from the caregiver with a 24-hour phone number for the caregiver to call and speak with a healthcare professional •A plan for transportation home from the hospital or to another facility
LIFE’s Vintage Guide • Your Guide to Discharge Planning
www.LIFEseniorservices.org