repisodic Blog

Discharge planning is a key component to a healthy recovery journey. By collaborating with your physicians, care team, and follow-up care providers, you can improve health outcomes and reduce the chance of readmission to the hospital due to health complications while also reducing out-of-pocket healthcare costs. This checklist, from a guide by the National Center on Caregiving, will walk you through key questions to ask and topics to consider as you or your loved one makes the care transition out of the hospital.

About the Illness

• What is the diagnosis and what can I expect?
• What should I look out for?
• Will we get home care and will a nurse or therapist come to our home? Who will pay for this service?
• How do I get advice about care, danger signs, or follow-up medical appointments?
• What is a phone number for someone to talk to?
• Have I been given information either verbally or in writing that I understand and can refer to?
• Do we need special instructions because my relative has Alzheimer’s or memory loss?

About Follow-Up Care

• What health professionals will my family member need to see?
• Have these appointments been made? If not, whom should I call to make these appointments?
• Where will the appointment be? In an office, at home, somewhere else?
• What transportation arrangements need to be made?
• How will our regular doctor learn what happened in the hospital or rehab facility?
• Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?

Kind of Care Needed

• Bathing
• Dressing
• Eating (are there dietary restrictions?)
• Personal hygiene
• Grooming
• Toileting
• Transfer from bed to chair?
• Mobility
• Medications
• Managing symptoms (e.g., pain or nausea)
• Special equipment
• Coordinating the patient’s medical care
• Transportation
• Household chores
• Taking care of finances

Discharge to Home

• Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment?
• Are there stairs?
• Will we need a ramp, handrails, grab bars?
• Are hazards such as area rugs and electric cords out of the way?
• Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment?
• Who pays for these items?
• Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?
• Will insurance/Medicare/Medicaid pay for these?
• Do I need to hire additional help?

About Training

• Are there special care techniques I need to learn for things like changing dressings, helping someone swallow a pill, giving injections, using special equipment?
• Have I been trained in transfer skills and preventing falls?
• Do I know how to turn someone in bed so they don’t get bedsores?
• Who will train me and when?
• Can I begin the training in the hospital?

About Medications

• Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken?
• How will we know that the medicine is effective?
• Will this medicine interact with other medications? Is it prescription, non-prescription, or herbal supplements that my relative is taking now?
• Should this medicine be taken with food? Are there any foods or beverages to avoid?
• Can this medicine be chewed, crushed, dissolved, or mixed with other medicines?
• What possible side-effects might I experience with the medicine? At what point should I report these problems?
• Will the insurance program pay for this medicine? Is there a less expensive alternative?
• Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling?

Elder Care Solutions in the Community

• What agencies are available to help me with transportation or meals?
• What is adult day care and how do I find out about it?
• What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services?
• Where do I start to look for such care?

Discharge to Residential Facility

• How long is my relative expected to remain in the facility?
• Who will select the facility?
• Have I checked online resources such as www.repisodic.com for ratings?
• Is the facility clean, well kept, quiet, a comfortable temperature?
• Does the facility have experience working with families of my culture/language?
• Does the staff speak our language?
• Is the food culturally appropriate?
• Is the building safe (smoke detectors, sprinkler system, marked exits)?
• Is the location convenient? Do I have transportation to get there?

Caregiver Needs

• Will someone come to my home to do an assessment to see if we need home modifications?
• What services will help me care for myself?
• Does my family member require help at night? If so, how will I get enough sleep?
• Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper?
• What medical conditions and limitations do I have that make providing this care difficult?
• Where can I find counseling and support groups?
• Can I get a leave from my job to provide care?
• How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs?

For Longer Stays

• How many staff are on duty at any given time?
• What is the staff turnover rate?
• Is there a social worker?
• Do residents have safe access to the outdoors?
• Are there special facilities/programs for dementia patients?
• Are there means for families to interact with staff?
• Is the staff welcoming to families?

Download this guide as a PDF: Hospital Discharge Planning Checklist

Additionally, you can download our Medication List and Appointment List to help you keep track of your loved one’s post-hospital care.