Hospital Discharge Planning

An elderly patient’s discharge from a hospital can be a very smooth transition or one fraught with uncertainties.  It depends on the patient’s medical needs and the financial means to meet those needs.

The hospital’s discharge planner has a herculean task: to obtain the highest level of care that’s possible.

The discharge planner (case worker or social worker) will evaluate a variety of issues to accomplish this task.  These include, among other things, a thorough evaluation of the elderly patient to identify:

Medical needs.   Prescriptions, medical equipment and techniques, specialized training, physical therapy, wound treatment, injections, and all other medical treatments the patient might require.

Personal care.     Eating, dressing, bathing, toileting.

Household care.  Cooking, cleaning, laundry, shopping.

Emotional care.   Companionship, activities, intellectual stimulation.

Financial ability.   The discharge planner can’t perform miracles by creating more income and assets for the patient’s care.  However, they can assist the patient and their family by providing information regarding health insurance coverage and/or direct them to the proper insurance representatives who can provide the necessary answers.

Few elderly patients have sufficient private health insurance and/or their own nest eggs to pay for all of the costs needed to obtain the highest level of care that’s possible.  The discharge planner must balance those needs with the patient’s realistic ability to pay for such care.

Communication between the patient (and family members) and the hospital’s discharge planning team is crucial.  While the doctors can identify the patient’s medical needs, his/her family members are best informed about the elderly patient’s history and the ability of family members to devote the time (and money) toward caregiving services.

The discharge planning team must also consider alternative placement if a discharge to the patient’s home isn’t medically and/or economically feasible.  This can involve a rehabilitation (short-term) facility or, as a last resort, a long-term care skilled nursing facility.

In California, a nursing home placement should always include an analysis of whether Medi-Cal benefits are available to pay for the high monthly costs. 

Caveat:  The laws and regulations governing Medi-Cal eligibility, share of cost, and recovery issues are complicated.  A little legal knowledge is generally dangerous, and this is particularly true of Medi-Cal planning.  Seek professional counsel.

Remember:  Discharge planners are performing their professional duties under pressure – pressure from their hospital administrators, doctors, other members of the discharge team and, perhaps most of all, the patient and family members.  The discharge needs of each patient are different – no one size fits all.

Work with your discharge planner.  Communicate regularly and attend all team meetings.  Write out all of your questions in advance.  Make sure you explain all of the patient’s needs and then offer practical solutions to make the transition go as smoothly as possible.  Together, you’ll obtain the highest level of care for your elderly loved one.