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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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What Can You Do To Ensure a Safe Hospital Discharge for Elderly Loved Ones?


As our previous blog post points out, the hospital discharge process is a key transition time. Without proper support and resources as well as good understanding of follow up instructions, many individuals will return to the hospital for reasons that could have been avoided. No one wants this, and it can be especially dangerous for elders and persons with chronic conditions.

If you are a family caregiver and an elderly loved one is hospitalized what can you do to ensure a safe transition after the hospital stay?

Consider the discharge process as beginning at the start of the hospital stay. Find out who is responsible for discharge planning and introduce yourself, explaining that you will be involved and giving relevant information about the patient’s living situation, supports and concerns. Discharge may not seem like a top concern at the beginning of a hospital stay, but with shorter hospital stay lengths, good groundwork starts as soon as possible.

Keep good records. An online personal medical record system is an ideal way to manage your loved one’s health history, medications, and store key contacts so this information can be readily available. You can also use a notebook or file to store the information, as long as you have it available and provide good information to new providers. Make sure you communicate information that is vital to your loved one’s health, such as medications that really should not be changed or typical complications or concerns that arise during hospitalization or procedures.

Get to know the medical staff and check in about what is going on throughout the stay. Ask questions (and keep records as per above) about procedures, tests, expected outcomes, medications.

Understand that you or a designated patient advocate will need to take charge in being the centralized hub of information. This includes ensuring you understand instructions, what will happen after discharge, and the functional status of the person (and therefore what support might be needed). Ask questions and anticipate concerns that might arise and do not hesitate to voice them.

Consider using a professional patient advocate for consulting or assessment during this process. Aging Wisely’s Care Managers know the discharge process, use a systematic approach and can help families anticipate needs and find resources to help. If you are caregiving from a distance, this support is vital as it is very difficult to manage the discharge process from afar.

Plan for the immediate transition time. The first day or two after discharge can be particularly problematic. Think about practical issues such as getting new medications, food and personal items while needing to attend to a person in a weakened state. Will you be able to help the patient from bed to bathroom? Services such as Medicare home health care and medical equipment rarely arrive immediately and are not meant to fulfill “custodial” needs, so you may need additional home caregiver support.

Find out about the options for services and rehabilitation after the hospital stay. There are essentially three rehabilitation options: inpatient (i.e. at a skilled nursing facility/rehabilitation center), home health care (for someone who is considered homebound) and outpatient rehabilitation (going to a clinic or center to receive therapy). We will cover these in more depth in a future post, including the insurance ins and outs & we invite you to contact us if you have immediate questions.

Ask for thorough discharge instructions in laymen’s terms and explain that you would like to be there when they are reviewed with the patient. Make a list of questions and help ensure you and your loved one are clear on instructions and who to contact if there is a problem later. Here is one example of a simple discharge form that you can provide if the hospital does not have one.

Know your patient’s rights, including the option to appeal a discharge if additional planning needs to be done to ensure a safe discharge.

Our next blog post will contain a checklist of items to consider and ask about when preparing for your elderly family member’s discharge, as well as more on resources to help during the transition of care.

Contact us if you have immediate questions. Our Florida geriatric care managers serve as your professional patient advocate, providing caregiver support and consultation, as well as geriatric assessments and resources.

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