To Prepare a Patient for Discharge, Hospitals Educate and Train Patients and Caregivers About Necessary Care Needs 
Hospital discharge planners provide patients with a list of instructions for post hospitalization care and information on medications. They also arrange referrals for other care, including referrals to physicians, home health, skilled nursing facilities (SNFs), hospice agencies, and medical equipment suppliers. Further, they provide information on community services for financial assistance, transportation, meal preparation, and other needs. Discharged patients and caregivers should be instructed what to do if problems occur, including who to call and when to seek emergency help.Patients receive instructions for follow up with their primary care provider (PCP) and other providers involved in their care. Hospital staff will advise them to schedule a follow-up visit with their providers soon after discharge. Some hospitals help to schedule these follow-up appointments. Hospital staff should send their patients’ providers information about their medical condition no later than seven days after they leave the hospital. Keep in mind that Medicare pays for the PCP to manage care after discharge.
BrightStar Care of Fredericksburg & Springfield helps hospitals coordinate patient care at home, including medication management, wound care, skilled nursing, and RN infusion services.
To learn more how BrightStar Care works with discharge planners and social workers to support a patient after hospitalization, please visit our Transitional Care Services page on our website.
Source: https://www.caregiver.org/hospital-discharge-planning-guide-families-and-caregivers