A Hospital Discharge Plan Can Better Prepare You for a Successful Transition from Hospital to Home
Understanding the process and benefits of a hospital discharge plan can better prepare you for a successful
transition from hospital to home and can help you avoid future readmission.Medicare requires inpatient discharge planning to be provided by hospital social workers and/or case managers to evaluate your medical condition(s) and decide what kind of aftercare is needed.
Your input and that of your caregiver will help the hospital social worker and case manager to comprehend your rehabilitation needs for returning home or to another facility. The hospital may recommend home care or an alternative as a more suitable environment to meet your daily health requirements. The case manager will arrange for you referrals to physicians, skilled nursing facilities (SNF's), medical equipment suppliers, in- home care and hospice agencies.
The hospital case manager should be knowledgable of both Medicare and Medicaid and which post-discharge health care services are covered, the costs, and cost applications. Make sure to find out which services are covered if you have other insurance plans.
Hospital social workers are there to teach you and your caregivers every aspect of your aftercare needs and assure you are ready to leave the hospital. Make sure the instructions and information given by the hospital are clear for all medications, resources for financial assistance, transportation services and services that provide for your in-home care needs. A list of numbers to call in case of an emergency and detailed instructions to follow if difficulties come up, is important for you to have.
After your discharge, one of the first assignments the social worker will have you do is to contact your primary care physician (PCP) and schedule a follow-up exam. Some hospitals will help you with appointments before you leave, but remember to make appointments with all of your care providers. Your health care providers should receive the hospital's information of your medical condition within the first week of being discharged.
BrightStar Care of Wellington and Palm Beach works closely with discharge planners, physician offices, and social workers to ensure continuation of care at home after a hospitalization.