Hospital Discharge Planning is Key to Recovery

hospital discharge planning - woman talking with doctor

Hospital coverage and inpatient hospital care are crucial for the recovery of many acute illnesses and injuries. Yet a common misconception among patients is that they will remain in the hospital until they feel “well enough” to go home. Instead, hospitals only keep patients for as long as a high intensity of medical care is needed. Most of a patient’s recovery actually happens outside of the hospital, either first at a rehabilitation or skilled nursing facility and then at home, or just at home with extra support.

This common misconception of being able to stay in the hospital until feeling well can lead to feelings of panic and stress when learning that yourself or a loved one will be discharged soon. This article reviews some of the important features of a hospital discharge plan, some tools to make the plan more “user-friendly” and accessible to you and your loved ones, and what to do if you disagree with a discharge notice and want to appeal. For more information and details on this whole process, see Livanta’s article: Supporting the Healthcare Journey Through Effective Discharge Planning.

Elements of a hospital discharge plan

When it’s time for a patient to be transitioned either to another care facility (i.e. a rehabilitation facility) or home, their doctor, social worker and hospital discharge planner will together create a hospital discharge plan. This plan identifies and prepares for a patient’s anticipated health care needs after they leave the hospital. Some elements to be included in the plan are:

  • A list of medications, doses, and instructions;
  • Dietary restrictions or guidelines;
  • Follow-up appointments with primary care doctors, specialists, clinics, or other providers;
  • Prescriptions for new medications or durable medical equipment;
  • Orders and paperwork to complete laboratory work or other tests or procedures; and
  • Any other factors that are critical to the patient’s recovery.

If done right, this plan creates a roadmap to ensure the full and smooth recovery of a patient as s/he transitions from the hospital and completes their healing journey elsewhere and at home. While this is the goal, sometimes patients, family members and/or caregivers have trouble deciphering medical jargon, have a language barrier, or for financial or other reasons aren’t able to implement all the elements of the care plan.

Tool to help create a “user-friendly” discharge plan

Because following the plan is crucial for a patient’s recovery, making sure everyone (patient, family members and other caregivers) understand it is key ingredient for success. To this end, Medicare has created a checklist for patients and caregivers to use and to use early in the discharge planning process. It is designed to help them understand each step, ask questions throughout the planning stage, and make notes.

You can access the tool here: Your Discharge Planning Checklist (PDF).

How to appeal a hospital discharge notice

If you or a loved one disagrees with a notice of discharge and/or termination of services, you have the right to appeal to your Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). The BFCC-QIO covering California is Livanta, and Livanta contracts with the Centers for Medicare & Medicaid Services (CMS) to provide congressionally-mandated assistance, appeals and quality protection to Medicare beneficiaries.

As stated in one of Livanta’s recent articles on hospital discharge, “all beneficiaries who are admitted to an inpatient hospital have the right to appeal a decision to end Medicare coverage at that level of care (also known as a “discharge decision”). The same appeal rights are provided to Medicare patients receiving skilled nursing, hospice, comprehensive rehabilitation, or home health services when the decision to end Medicare coverage for these services at that level of care has occurred.” 

When a patient or a patient’s representative calls Livanta’s Medicare helpline to initiate appeals, Livanta staff will obtain their medical records and begin the review process. Most of the cases are completed within 24 to 48 hours. Additionally, Livanta’s Immediate Advocacy Team may be able to mediate and resolve the patient’s concerns about their pending discharge. For more information, see their website.

For more information on hospital discharge planning, see Livanta’s article: Supporting the Healthcare Journey Through Effective Discharge Planning.

Karen Joy Fletcher

Our blogger Karen Joy Fletcher is CHA’s Communications Director. With a Masters in Public Health from UC Berkeley, she is the online “public face” of the organization, provides technical expertise, writing and research on Medicare and other health care issues. She is responsible for digital content creation, management of CHA’s editorial calendar, and managing all aspects of CHA’s social media presence. She loves being a “communicator” and enjoys networking and collaborating with the passionate people and agencies in the health advocacy field. See her current articles.