Patient Referral

How to Work with Hospital Discharge Planners

working with discharge planners

When a loved one is admitted to the hospital, their family often rallies with thoughts and prayers that their loved one will soon be discharged. The hospital discharge planner is the patient’s ally in making sure this transition from the hospital to home, a nursing home, assisted living, or rehabilitation facility goes smoothly. Good communication between the family, facilities, and the discharge planner is essential.

The Team Approach to Discharge Planning

While the physician is the only one who can authorize a patient’s discharge, the actual work of planning where the patient will go is typically handled by the discharge planner in conjunction with the doctors, nurses, case managers, social workers, and family.

A patient will first be evaluated to determine what level of care will be needed after discharge. If they are transitioning to a rehabilitation facility, it is important to discuss the goals of that care so everyone is on the same page of what to expect in terms of length of stay and what the next steps will be. It’s also important to review what medications and care will be administered during their time at the facility.

If the patient is returning home, the family may need the support of palliative care or hospice care to help ensure all of the patient’s needs are met. In an assisted living facility, palliative or hospice care supplements the care being provided by the facility to ensure the patient’s pain and symptoms are well managed and that their emotional and spiritual needs are being met.

discharge to hospice

Transitioning from Hospital to Home on Hospice

When a patient is discharged from the hospital on hospice care, the hospital discharge planner will work with the hospice admissions team and case manager to make it a smooth process.

Crossroads Hospice & Palliative Care can meet the patient and their family at the hospital or another convenient location to assess the patient for hospice eligibility and to sign consents. Beginning hospice care can be an emotional decision, and our admission team is available 24 hours a day, 7 days a week to answer questions and admit patients to make it as easy on the patient and their family as possible.

If medical equipment and supplies including hospital beds, wheelchairs, or incontinence supplies are needed, they will be scheduled to be delivered to the home before the patient arrives. Medications will also be ordered through the hospice and delivered to the home so there is no gap in the patient’s medication. All medical equipment, supplies, and medication related to the patient’s hospice diagnosis is provided at no cost to the patient or family.

Why is discharge planning important?

When a discharge is planned effectively, the patient should not need to be readmitted to the hospital anytime soon. Good planning and support from the palliative or hospice care team can ensure that pain and symptoms are managed wherever the patient resides, which reduces the need for emergency room visits.

Family caregivers can assist in a good discharge plan by being open and honest about the patient’s living situation and the ability to provide care in the home. They should let the discharge planner know if there are financial concerns, work obligations, or even physical limitations that could affect the family’s ability to provide care at home. If a caregiver cannot aid in lifting a patient or if a wheelchair won’t be able to maneuver in the home, it’s important to mention this ahead of time so that an appropriate plan can be put in place.

To learn more about how hospice and palliative care supports patients transitioning home from the hospital, please call 1-888-564-3405.


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Copyright © 2019 Crossroads Hospice & Palliative Care. All rights reserved.

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