Post-Rehabilitation Discharge Planning for Seniors

Last Updated: July 5, 2019

Studies have shown that improvements in hospital discharge planning also improve the outcome for patients as they transition to the next level of care. However, rehabilitation discharge planning can be a difficult task in an already intensive time. Families, healthcare providers and nursing homes all play key roles in maintaining a patient’s health after discharge, but there is a surprising lack of consistency in the process and quality of discharge planning.

Learn more about post-rehabilitation discharge planning for seniors.

6 Steps to Being Discharged From the Hospital

Only a doctor can authorize a patient’s release from the hospital. Then, after this has been completed, the process of discharge planning can begin.

Discharge planning can be completed by a case manager, nurse, social worker or another appointed individual. Ideally, discharge planning should be done using a team approach to ensure the patient’s transition will be successful.

Steps to being discharged include:

Hospital personnel, who will evaluate the patient and their condition.
Hospital personnel and a patient’s family, who will discuss the patient’s condition upon arrival and current condition, as well as suggested next steps as to what types of care will be needed going forward and information on whether the patient’s condition is likely to improve. Also, what extra equipment may be needed and information on medications and any restrictions, will be discussed.
The family can then begin planning the patient’s discharge to either their home or transfer to another care facility like a nursing home.
Then, qualified hospital personnel will determine if caregiver training or additional support is needed.
The patient and their family will then receive referrals to a home care agency and/or the appropriate support organization.
Ultimately, qualified hospital personnel will arrange any follow-up appointments or tests.

Your Discharge Planning Checklist for Seniors

This discharge planning checklist can help families better transition patients to a home, nursing home care or a rehabilitation facility.

Before being discharged, consider asking:

Questions to Ask Before a Discharge

Ask the hospital where the patient should go after they are discharged (a home, nursing home or rehabilitation facility) and find out what the patient’s options are as well as how long they are expected to remain there.
Ask the hospital staff any and all questions you and the patient have about the patient’s condition and what can be done to help make improvements.
Ask the hospital staff what problems to watch for and what to do about them if they occur. Write down a name and phone number of someone from the hospital you can call if the patient experiences any problems.
Make a list of the prescription drugs, over-the-counter drugs and vitamins the patient is taking. Review the list with the hospital staff and tell them what drugs, vitamins or supplements the patient was taking prior to being admitted to see if they should still take these after they leave. Write down a name and phone number of someone from the hospital you can call if any questions arise. Additionally, on the patient’s drug list, include: dose, drug name, how to take it, what it does and when to take it.
Ask if medical equipment will be needed and find out who will be arranging this. Write down a name and phone number of someone you can call if you have any questions about equipment.
Ask if the patient is ready to do the following activities:
- Bathing
- Cooking
- Dressing
- Grocery shopping
- House cleaning
- Paying bills
- Running errands
- Using the bathroom

Questions to Ask About Follow-Up Care

Does the patient have or will he/she need support (like a caregiver) in place?
How do you complete any medical tasks that require special knowledge (changing bandages or giving a shot)?
What discharge instructions are there and what is the summary of a patient’s health status?
What will insurance cover going forward?

What to Know After a Discharge

Patients should be called 2-3 days after discharge from a member of the hospital’s clinical staff. This phone call allows for the patient to ask any questions they may have surrounding their health, care and/or discharge plan, as well as any additional concerns from family members or caregivers.

The clinical staff member should review with each patient their:

Appointments
Health status
Medications
Plan for what to do if a problem occurs
Services

Post-Rehabilitation Resources

The Medicare-approved agencies listed here have information on community services that may help in making long-term care decisions:

Area Agencies on Aging (AAA) and Aging and Disability Resource Centers (ADRCs): AAA and ADRC help older adults, people with disabilities and caregivers. To find the AAA or ADRC in your area, visit: eldercare.gov.
Long-term Care (LTC) Ombudsman Program: LTC promotes the rights and is an advocate for residents in LTC facilities. For more information, visit: ltcombudsman.org.
National Council on Aging: Provides information about programs that can help pay for prescription drugs, utility bills, meals, health care and more. For more information, visit: benefitscheckup.org.
Senior Medicare Patrol (SMP) Programs: SMP works with seniors to protect them from the economic and health-related consequences of Medicare and Medicaid fraud, abuse or error. To find your local SMP program, visit: smpresource.org.
State Health Insurance Assistance Programs (SHIPs): Provides counseling on health insurance and programs for people with limited income. Help with appeals, billing and claims. For more information, visit: shiptacenter.org.
State Technology Assistance Project: Provides information on medical equipment and other assistive technology. For more information, visit: resna.org.