Hospital Discharge Planning and Medicare

In this article...
  • Learn about discharging planning and how it can help you or a loved one transition from a hospital stay to life at home or another health facility, especially if you're a Medicare beneficiary.

Receiving the green light to leave hospital and return home is typically good news for patients and their families. But before you head for the exit, it’s crucial to have a discharge plan in place. 

Discharge planning is essential for anyone who has been hospitalized. It involves the process of making arrangements to transition a patient back into their community following an admission. 

There are many things to consider during this process, including the type of care the patient will need, where they will receive it, and who can support them in these activities at home or elsewhere. The plan ensures someone has everything they need when it comes time to go home from the hospital. 

This article covers hospital discharge planning and what to expect from the process.

What Is the Discharge Procedure?

Discharge procedures vary slightly from hospital to hospital. However, most health facilities follow a similar process:

  • When a patient no longer requires care, and their physician authorizes their discharge, a discharge planner or other hospital representative informs them they are ready to leave. They advise whether the patient can return home or another location, such as a rehabilitation facility or aged care home.

  • The patient receives a copy of the signed Important Message from Medicare (IM or IMM). Hospitals issue this document no more than two days before discharge but as soon as practically possible. It is not issued for stays of three days or less.

  • The discharge planner helps the patient understand the ongoing care and treatment they require for their injury or illness. They also provide information on who to contact with any questions or problems. 

  • The discharge planner contacts the outside healthcare professionals who’ll manage the patient’s ongoing care. They inform them of the treatment the patient received in the hospital and the recommended plan going forward.

  • Before leaving the hospital, the care team, patient, and their caregiver attend a planning meeting. This is usually held one or two days before discharge. The patient receives more information about the discharge process and usually makes follow-up appointments at this time.

  • On the day of discharge, the hospital care team holds a discharge meeting with the patient and their carers. They review medication, follow-up appointment schedule, and emergency contact details. They should also provide a written health summary for the patient’s records.

  • The patient leaves the hospital and follows the recommended treatment plan to minimize the risk of readmission.

What Is the Purpose of Discharge Planning?

When someone leaves the hospital, it can be a vulnerable time. Discharge planning ensures that patients are safe and well cared for in their home environment and are ready for life after their hospital stay. A solid plan allows for consistent and high-quality care that helps recovery to go smoothly.

The process allows the patient, caregivers, and healthcare providers to understand their roles following hospital discharge. It includes helping people understand what medications they should be taking, how often they need to see their doctor, and ensuring that any medical supplies or equipment are correctly used. 

What Should a Discharge Plan Include?

A discharge plan should include the following elements:

  • The patient’s health: Including the name of any health condition, strategies for improving health, and any symptoms that may suggest health is improving or deteriorating.

  • Care after discharge: Details of the patient’s care plan after leaving the hospital, noting if they’ll return home, enter a rehabilitation facility or nursing home. If the patient receives home care, it should include the name and contact number of the home care provider.

  • Medication list: A list of all medications the patient is taking, including those related to the current or recent health complication, other prescription medication, over-the-counter medicines, vitamins, and health supplements. There should be details of the medication schedule moving forward.

  • Additional aids: Details of necessary mobility or other aids to help the patient transition out of the hospital and how to obtain them. There should also be a contact name and phone number to help with questions and concerns about the equipment.

  • Skill training: Note any special skills the patient or carer needs after discharge, such as changing bandages or administering shots. The health team should provide coaching or demonstrations of any unfamiliar skills.

  • Recovery and support: This section lists daily tasks such as dressing, bathing, cooking, and shopping and notes whether the patient can perform these tasks independently. If the patient needs assistance, it should include contact names and numbers for support.

  • Hospital contact: Includes the name and phone number of the best person to contact from the hospital with any follow-up questions or concerns.

  • Follow-up appointments: Details the dates and times of follow-up appointments at the hospital or other facility.

The Importance of Discharge Planning

Many patients look forward to returning home after a hospital stay, but leaving the constant care of trained medical professionals can also be daunting. 

Creating a discharge plan can help you or a loved one successfully transition out of the hospital system and reduce the chances of readmission.

About the Author

Zia Sherrell is a digital health journalist with over a decade of healthcare experience, a bachelor’s degree in science from the University of Leeds and a master’s degree in public health from the University of Manchester. Her work has appeared in Netdoctor, Medical News Today, Healthline, Business Insider, Cosmopolitan, Yahoo, Harper's Bazaar, Men's Health and more.

When she’s not typing madly, Zia enjoys traveling and chasing after her dogs.

Read More
A couple uses their laptop computer while having coffee
This step-by-step guide can help you compare Medicare Advantage (Part C) plans to find the right type ...
Woman walks in a garden with assistance from caregiver
Medicare Part A and Medicare Advantage plans can help cover costs of stays in a skilled nursing facility ...