Hospital discharge planning is a process that determines the kind of care you need after you leave the hospital. Discharge plans can help prevent future readmissions, and they should make your move from the hospital to your home or another facility as safe as possible.

Medicare requires hospitals to screen inpatients and provide discharge planning for those who need it. However, screening is only mandatory for hospital inpatients. If you are an outpatient (possibly you are on observation status), Medicare does not require screening or discharge planning. Some states may provide outpatients with rights to discharge planning services. For more information on discharge planning in your state, please contact your State Health Insurance Assistance Program (SHIP).

Your discharge plan should include information about where you will be discharged to, the types of care you need, and who will provide that care. It should be written in simple language and include a complete list of your medications with dosages and usage information. To help ensure that your discharge is successful, keep the following in mind:

  1. If you are concerned, ask your provider for a discharge planning evaluation. Some hospitals automatically evaluate the discharge needs of all patients, but others do not. You, your caregiver, and/or your provider can request screening for discharge planning.
  2. When developing your discharge plan, the hospital should connect with you or your representatives and, if possible, incorporate your requests. After your evaluation is completed, hospital staff should give you the opportunity to provide feedback.
  3. The hospital’s main goal should be for you to return to the place you left before your hospital stay. This may be your home or another facility. If this is notpossible, the hospital should recommend other, more appropriate places for you.
  4. Make sure hospital staff members consider your full range of needs when creating your discharge plan. If you are returning home, hospital staff must evaluate your need for home health care, meal delivery, caregivers, durable medical equipment (DME), and changes to your home to ensure safety. If you are returning to a facility, the hospital must make sure the facility can still manage your health care needs.
  5. Review which post-discharge services will be covered by Medicare and how much they will cost. The hospital should be aware of what Medicare does and does not cover and should tell you when costs may apply.
    1. If you have another type of insurance, such as Medicaid, check which services it covers as well. The hospital should also be familiar with Medicaid’s coverage rules for certain services, such as personal care and long-term care.
  6. Be sure the hospital prepares you for discharge. Before you leave the hospital, staff must educate and train you and/or your caregivers about your care needs.
    1. Staff should provide a clear list of instructions for your care and information on all medications you take.
    2. Staff must arrange all referrals for other care, including referrals to physicians, home health, skilled nursing facilities (SNFs), hospice agencies, and DME suppliers. They should also put you in touch with community services that help with financial assistance, transportation, meal preparation, and other needs.
      • The hospital is required to provide you with a list of home health agencies or SNFs in your area that participate in Medicare.
    3. You or your caregiver should be told what to do if problems occur, including who to call and when to seek emergency help.
  7. Follow up with your primary care provider (PCP) and other providers involved in your care. Hospital staff should advise you to schedule a follow-up visit with your providers soon after your discharge. Some hospitals help you schedule these follow-up appointments. Hospital staff should send your providers information about your medical condition no later than seven days after you leave the hospital. Keep in mind that Medicare pays for your PCP to manage your care after you are discharged..

 

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