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Discharge Planning News


hospital discharge planning

As advocates for our elder loved ones, we need to be particularly aware of the potential risks they face during and after a hospitalization. More attention is being paid to discharge planning and hospital readmissions in recent years and efforts are being made to improve care coordination and discharge planning.

Thanks to Elizabeth E. Hogue, Esq.* who recently shared this news on proposed changes to discharge planning regulations (published November 3, 2015).

Proposed changes in Conditions of Participation (CoPs) for hospitals generally require:
  • Development and implementation of an effective discharge planning process that focuses on patients’ goals and preferences, and prepares patients and their caregivers/support person(s) to be active partners in post-discharge care
  • Planning for care that is consistent with patients’ goals for care and treatment preferences
  • Effective transition of patients from hospitals to post-discharge care
  • Reducing factors leading to preventable hospital readmissions

The proposed regulations require the discharge planning process to be applied to all inpatients, patients under observation status, outpatients undergoing surgery or procedures in which they receive anesthesia or moderate sedation, ER patients identified by discharge planning policies, and any other categories of outpatients recommended by the medical staff/specified in the hospital discharge planning policies.

In addition, hospitals will also be required to do the following:

  • Discharge planning processes must require regular re-evaluation of patients’ conditions to identify changes that require modification of discharge plans. Discharge plans must also be updated on an as-needed basis.
  • Practitioners responsible for patient care must be involved in the ongoing process of establishing patients’ goals of care and treatment preferences.
  • Hospitals must also consider patients’, caregiver/support persons’ and community-based caregivers’ capabilities to perform necessary care.
Specifically hospitals would be required to consider the following when evaluating patients’ discharge planning needs:
  • Admitting diagnosis (or registration reason)
  • Relevant co-morbidities, medical history
  • Anticipated ongoing care needs
  • Readmission risk
  • Relevant psychosocial history
  • Communication needs, including language barriers, diminished hearing and eyesight, and self-reported literacy of patients/ patients’ representatives or caregivers
  • Patients’ access to services and community-based care providers
  • Patients’ goals and preferences

In addition, patients and caregivers must be involved in the development of discharge plans and informed of final plans to prepare them for post-discharge.

Hospitals must also assist patients and their families or representatives to select post-acute providers by using and sharing data on quality measures for home health agencies, nursing facilities, inpatient rehab facilities and long-term care hospitals. Data must be relevant and applicable to patients’ goals and treatment preferences.

Discharge planning evaluations must be documented, completed on a timely basis and included in patients’ medical records. There are a number of specified requirements under these proposed changes, hopefully with positive effects for you as a patient or caregiver. To receive emails from Elizabeth Hogue, Esq. email her at ElizabethHogue(at)

We’ll keep you updated on the latest discharge planning news and tips. For more information about discharge planning check out:

Safe Discharge Planning for Your Elderly Loved Ones
Hospital Discharge Planning Checklist
Reducing Hospital Readmissions: Senior Care in Discharge Planning

Contact our team at 727-447-5845 for questions or assistance with discharge planning and all aspects of aging wisely and well.

Excerpted from information by Elizabeth E. Hogue, Esq., ©2015 Elizabeth E. Hogue, Esq.  All rights reserved.

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Hospital Discharge: Checklist for Families


Our previous blog posts have covered the Challenges of Hospital Discharge for Elders and Ways You Can Help an Aging Loved One Have a Safe Hospital Discharge. Now we will share some important questions you should ask (a checklist of sorts) in the hospital discharge process.

Did I get written discharge instructions explained to me with time to ask questions and clarify any concerns? Items that should be included:

o Reason for admission, procedures done, outcome
o Do we know who to contact if we have a problem after discharge?
o What symptoms should we be watching for and what do we do if we have a concern?
o Medication list (and how will I make sure all my doctors & providers are updated with the new list)
o Follow up appointments

Get information about follow up treatment and therapy that might be essential to recuperation. Find out:

o Will I be receiving therapy services at home, inpatient or outpatient? You will need to select a provider and the hospital will generally provide a list of options if you ask, but you should do your research so that you can make an educated choice. There is information online about provider outcomes and you may wish to check with your loved one’s doctor or geriatric care manager for recommendations.
o Does insurance cover these services (your insurance may impact the choice of provider)?
o How long can they be expected to last? What outcome is expected? (Share your goals and concerns as well.)

Find out about the patient’s home care needs and what assistance may be needed in the weeks following the hospitalization. Issues to consider:

o Patient’s functional status: strength, ability to transfer safely, bathing, dressing, weakness, physical limitations.
o Household needs: can the patient take care of the household? Do laundry, clean? Help preparing meals (in compliance with nutritional needs/medical orders)?
o Transportation: will the patient need rides to appointments or help with errands?
o Medication management: consider how the patient will get new medications and discard old ones properly, manage following a new medication routine, communicate changes to all doctors/providers?

*Most times, if a patient is returning home after a hospital stay, they will receive some Skilled Home Care services, covered under Medicare or insurance. These services often do not begin on the day of discharge and are not intended to cover custodial needs such as most of those listed above. Medicare may cover support from a home health aide, but only as long as the patient requires skilled services such as physical therapy or a R.N. (for example for dressing changes/wound care). If you have concerns about any of the areas above, you should talk to a licensed, private duty home care provider, such as our sister company EasyLiving, about affordable home care and transitional packages to fill any gaps.

Ensure the home environment will accommodate post-hospital needs:

o Is any special medical equipment needed? Have arrangements been made? Will equipment be delivered and when? Do I need to pick up equipment and where can I do so? Cost/insurance coverage?
o How safe is the home environment? Have we completed a home safety, falls prevention assessment?
o Does the patient have a Personal Emergency Response System in case he/she falls or needs to call for help?

If you would like professional advice on how to prepare for a hospital discharge, what resources are available and how to get the best after-care, Aging Wisely’s geriatric care managers provide caregiver consultations, in-hospital and home safety assessments and patient advocacy.

Our professional patient advocates are here to help-contact us today!

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Problematic Transitions of Care: Elderly Hospital Discharge & Readmissions


Everyone looks forward to being able to return to the comforts of home after being hospitalized. However, too many patients will quickly return, especially those over age 65 and with multiple conditions.


Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates.

Within 90 days of hospital discharge, as many as 35% of Medicare recipients will be readmitted to the hospital.

Those at highest risk have certain conditions such as heart failure, COPD (Chronic Obstructive Pulmonary Disease), Psychoses, Intestinal Problems or recent surgery; those taking 6 or more medications; and those being discharged on weekends or holidays. Older patients who live alone were twice as likely to be readmitted if they did not have supportive community services such as home care.


Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent could be minimized/improved.

“Decentralized responsibility is a central defect of the discharge process”, says Judith Black, M.D., MHA, medical director of senior products at Highmark Blue Cross Blue Shield. After a hip replacement, for example, an orthopedic surgeon writes orders, a primary care physician writes orders, and a case manager issues instructions. Patients are often confused and overwhelmed by the process, and even family caregivers often find they do not receive much communication or feel they understand the process.

Communication problems are thus one primary causes of problems after discharge. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Even when communication is good, patients are often groggy, medicated and overwhelmed. This is why it can be vital to have an advocate there to hear the instructions, ask questions and answer the patient’s questions later. Written instructions in laymen’s terms help as well.

Lack of good follow-up care and supportive services is another cause of preventable readmissions. Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. Family caregivers may not be prepared to care for a loved one who needs more physical assistance in a weakened state. The logistics of staying with someone while they are weak or on heavy medication and handling other responsibilities may be too much. Patients without local family support need coordinated services after they leave the hospital such as help with activities of daily living, household help, meal preparation, medication management, physical therapy, transportation to appointments.


Our sister company, EasyLiving, Inc. provides Pinellas County home care support services such as personal care (help with bathing, dressing, grooming), household help, medication management, transportation and a special Transitions of Care Program to help immediately after hospital discharge.

Aging Wisely’s patient advocate care managers can help with the hospital discharge process, ensuring a smooth transition for you or your loved one. We invite you to review our article on elder patient advocacy and contact us today for help.

Look for our future articles on solutions for hospital discharge problems, including a checklist of things you can do, resources, and ways to be prepared.

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