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Discharge Planning

How to Plan for Your Discharge: A Message for Our Medicare Patients

What is discharge planning?
Medicare defines discharge planning as a “process used to decide what a patient needs for a smooth move from one level of care to another.” Ideally, this planning begins during admission. Adjusting to the changes brought on by your illness and choosing from the various services available to meet your needs may leave you feeling overwhelmed. Sacred Heart Hospital has well-trained and experienced health care professionals (social workers) to meet with you, answer your questions, listen to your concerns, and assist you and your family with this process.

Who should have a discharge plan?
Discharge planning is appropriate for all patients. Your discharge plan may be as simple as a verbal understanding of your medications or as complex as a written plan of action upon discharge to a nursing facility. However, upon admission, discharge planners immediately look for patients who have special needs or risks. Special attention will be given to patients who are seriously ill; disabled; chronically ill (such as diabetics or those with heart or lung disease); unable to care for themselves medically, physically, socially, and emotionally; incompetent; homeless; without income; age 70 with a disability or living alone; and age 80 or over.

You should discuss anything with your health care team that could impact the types of after-hospital care you may need. For example: Do you live alone or have family or friends who can help? Do you have stairs or other obstacles in your home? Will you need assistance with personal care, medications, bandages, special equipment or therapy? Will you need a home health nurse? Will you need a nursing home for skilled care or custodial nursing care? Can meals be delivered to your home?

When everyone involved understands your health care needs, more informed decisions concerning needed arrangements can be made.

When will I be discharged?
Discharge occurs when symptoms have stabilized and further care can be provided in another setting. Medical advances enable discharge from a hospital when someone is not fully recovered. In addition, insurance regulations may often necessitate a shorter stay in a hospital.

Who determines when I get discharged?
Your physician will determine when your condition is stable and no longer requires hospital-level care. Your discharge plan may be for you to return home, to a relative’s home, a rehabilitation hospital, or a skilled nursing and rehabilitation facility (nursing home). The social workers will provide information about community resources available and offer guidance to help you make decisions.

Our goal is to help you formulate a plan that safely and adequately meets your needs. Successful discharge planning requires that you, the patient, and your family work closely with physicians, social workers, and case managers. We cannot perform discharge planning effectively without your help. We need your cooperation and assistance.

What services are available if I return home?
If you are able to return home or to a relative’s home, staff will provide you with a list of community home health services from which to choose. We will check with your insurance to ensure coverage for this service and set up visits prior to your departure from the hospital.

What if I need intensive rehabilitation?
Staff will request rehabilitation hospitals to review your case to determine if they can meet your needs. If rehabilitation is recommended at a less intensive level, you will be provided with a list of area skilled nursing facilities from which to choose.

Do I complete a generic nursing home application?
You will be given a generic nursing home application to complete in order to facilitate the skilled nursing facility admission process. We ask that the completed application, along with three initial choices of nursing homes, be returned to the social worker or case manager within 24 hours. Medicare requires that you take the first available bed. Your social worker will communicate with the facilities that you have chosen and send them the necessary paperwork to help them make a decision.

Refusal to cooperate with any of these guidelines could result in a termination of insurance benefits.

What about assisted living or personal care facilities?
If an assisted living or personal care facility placement is necessary, the process is similar. Please note, however, that admission to an assisted living facility or personal care facility is not covered by insurance.

We understand.
This is a difficult and anxious time for you and we encourage your participation to make the transition a smooth one. Our goal is to communicate all aspects of the discharge planning process in an open and honest manner. Our expectations of your role are high, but necessary, to reach the established goal of a safe and appropriate discharge.

Your social worker and case manager are here to assist you with all aspects of the discharge planning process. Please contact the Case Management Department at 610-776-4918 with any concerns or questions. Social work and case management assistance are available 7 days a week from 8:00 a.m. – 4:30 p.m.