Effective discharge planning can decrease the chances of the patient being readmitted to the hospital, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare caregivers to take over the patients care. Discharge planning begins when you are admitted to the hospital.

Basics of a discharge plan include:

• Evaluation of the patient by qualified personnel

• Discussion with the patient or their representative

• Planning for homecoming or transfer to another care facility

• Determining if caregiver training or other support is needed

• Referrals to home care agency and/or appropriate support organizations in the community

• Arranging for follow-up appointments or tests

Most people discharged from the hospital only require minimal care when they leave, but some people have more specialized care after leaving the hospital. The discharge planner discusses with the patients and/or caregiver, if applicable, their willingness and ability to provide care. Some of the care a patient needs at home might be quite complicated and require training. Other resources, such as home health care, might be necessary to properly care for a patient after discharged.

Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower re-hospitalization rates.

Additional Question for caregivers to ask:

• What is it and what can I expect?

• What should I watch out for?

• Will we get home care and will a nurse or therapist come to our home to work with my relative? Who pays for this service?

• How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments?

• 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?