Hospital Discharge Planning


Hospital Discharge Planning:  A Guide for Families and Caregivers

A trip to the hospital can be an intimidating event for patients and event for patients and their families.  As a caregiver, you are focused completely on your family member’s medical treatment, and so is the hospital staff.  You might not be giving much thought to what happens when you relative leaves the hospital.

Yet, the way this transition is handled – whether the discharge is to home, a rehabilitation (“rehab”) facility, or a nursing home – is critical to the health and well-being of your loved one.  Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care.

Patients, family caregivers and healthcare providers all play roles in maintaining a patient’s health after discharge.  And although it’s a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system.

This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one.  If you are a caregiver, you play an essential role in this discharge process; you are the advocate for the patient and for yourself.


What is discharge planning?

Discharge planning is “A process used to decide what a patient needs for a smooth move from one level of care to another”.  Only a doctor can authorise a patient’s release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager or other person.  Ideally, and especially for the most complicated medical conditions; discharge planning is done with a team approach.

In general, the basics of a discharge plan are:

  • Evaluation of the patient by qualified personnel
  • Discussion with the patient or his 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 organisations in the community
  • Arranging for follow-up appointments or tests.

The discussion needs to include the physical condition of your family member both before and after hospitalisation; details of the types of care that will be needed and whether discharge will be a facility or home.

It also should include information on whether the patient’s condition is likely to improve, what activities he or she might need help with, information on medications and diet, what extra equipment might be needed, such as a wheelchair, commode, oxygen; who will handle a meal preparation, transportation and chores and possibly referral to home care services.


Why is good discharge planning important?

Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, help in recovery, ensure medications are prescribed and given correctly and adequately prepare you to take over your loved one’s care.

Not all hospitals are successful in this.  Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good after care release.

Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving hospital and 18 percent of patients discharged from hospital are readmitted within 30 days.  This is not good for patient, not good for the hospital and not good for the financing agency.  On the other hand, research has shown that excellent planning and good follow-up can improve patient’s health, reduce readmissions and decrease healthcare costs.

Even simple measures help immensely.  For example, you should have a telephone number(s) accessible 24 hours a day including weekends, for care information.  A follow-up appointment to see the doctor should be arranged before your loved one leaves the hospital.  Since errors with medications are frequent and potentially dangerous, a thorough review of all medications should be an essential part of discharge planning.  Medications need to be “reconciled”, that is, the pre-hospitalisation medications compared with post-discharge list to see that there are no duplications, omissions or harmful side effects.

Under the best circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital.


The caregiver’s role in the discharge process

The discharge staff will not be familiar with all aspects of your relative’s situation.  As caregiver, you are the “expert” in your loved one’s history.  While you may not be a medical expert, if you’ve been a caregiver for a long time, you certainly know a lot about the patient and about your own abilities to provide care and a safe home setting.

The discharge planners should discuss with you your willingness and ability to provide care.  You may have a physical, financial or other limitations that affect your caregiving capabilities.  You may have other obligations such as a job or childcare that impact the time you have available. It is extremely important to tell the hospital staff about those limitations.

Some of the care your loved one needs might be quite complicated.  It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator or transferring someone from a bed to a chair.

If your loved one has memory problems caused by acquired brain injury, stroke, or another disorder; discharge planning becomes more complicated and you will need to be part of all discharge discussions.  You may need to remind the staff about special care and communication techniques needed for your loved one.  Even without impaired memory, people often have hearing or vision problems or are disorientated when they are in hospital so these conversations are difficult to comprehend. They need our help.

If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge.  Written materials must be provided in your language as well.  Studies have shown that numerous, and sometimes dangerous errors can be made in home care when language is not taken into account at discharge.

Because people  are in a hurry to leave the hospital or facility, it’s easy to forget what to ask.  We suggest you keep the questions on pages 5-6 with you, and request that the discharge planner take time to review them with you.


Getting help at home

Listed below are common care responsibilities you may be handling for your family member after he or she returns home:

  • Personal care: bathing, eating, dressing, toileting
  • Household care: cooking, cleaning, laundry, shopping
  • Healthcare: medication management, doctors appointments, physiotherapy, occupational therapy, speech and language therapy, dietician, wound treatment, injections, medical equipment and techniques
  • Emotional care: companionship, meaningful activities, conversation.

There are organisations that can help with services such as transportation, meals, support groups, counselling and possibly a break from your care responsibilities to allow you to rest and take care of yourself.  Finding those services can take some time and several phone calls.  The discharge planner should be familiar with the community support that is available, but if not, contact us to discuss your needs to see how we can help. Family and friends also might assist you with home care.

If you need to hire paid in-home help, you have some decisions to make.  Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. You might be handed a list of agencies, with instructions to decide which to use – but often without further information. This is another good reason discharge planning should start early – as caregiver, you will have time to research your options, while your loved one is cared for in hospital.

Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background.

You may have a choice between hiring an individual directly or going through a home care or home health care agency.  Part of that decision may be affected by whether the help will be “medically necessary”. i.e. prescribed by the doctor, and therefore paid for by the NHS or other insurance.  In that case, the funder will most likely determine the agency you use.


Discharge to a facility

If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patient’s health and capabilities, review medications and help you select the facility to which your loved one is to be released.

Too often, however, choosing a facility can be a source of stress for families.  You may have very little time and little information on which to base your decision.  You might simply be given a list of facilities and asked to choose one.  To help you, a social worker can offer much needed advice and support.

Convenience is a factor – you need to be able to easily get to the facility – but the quality of care is very important, and you may have to sacrifice your convenience for the sake of better care.  The list of questions on pages 5-6 will give you direction as you start your search for a facility.


Paying for care after discharge

You might not be aware the NHS does not pay for all services after a patient has been discharged from the hospital.  However, if something is determined by the doctor to be “medically necessary” you may be able to get coverage for certain skilled care or equipment.  You will need to check directly with the hospital, to find out what might be covered and what you will have to pay for.  Keep careful records of your conversations.


What if you feel its’s too early for discharge?

If you don’t agree that your loved one is ready for discharge, you have the right to appeal the decision.  Your first step is to talk with the physician and discharge planner and express your reservations.  The hospital staff will provide you with details of appeals process.  If that isn’t enough, you will need to contact someone who can advocate for your needs.


Improving the system

The discharge planning process varies from hospital to hospital.  Who does it, when it’s done, how it’s done, what kind of follow-up is mandated and whether caregivers are assessed for their ability to provide care and included as respected members of the discussion are all elements that differ from setting to setting.

In general, hospitals are funded when beds are occupied.  Despite its benefits, which clearly increase the wellbeing of the patients and caregivers, discharge/transition planning is often not given the attention it deserves, and indeed, ineffectual planning often serves to add to patients and caregivers’ stress.


Some Basic Questions for Caregivers to Ask

  1. Questions about the illness:
  • 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 often is it provided?
  • 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 can refer to?
  • Do we need special instructions because my relative has an acquired brain injury?
  1. What kind of care is needed?
  • Bathing
  • Dressing
  • Eating (are there diet restrictions e.g. soft foods only? Certain foods not allowed?)
  • Personal Hygiene
  • Grooming
  • Toileting
  • Transfer (moving from bed to chair)
  • Mobility (including walking)
  • Medications
  • Managing symptoms (e.g. pain or nausea)
  • Special equipment
  • Coordinating the patient’s medical care
  • House hold chores
  • Taking care of finances

     3.  Questions when my relative is being discharged from 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?
  • Who will pay for these?
  • Do I need to hire additional help?
  1. Questions about training:
  • Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment?
  • Have I been trained skills in transfer skills and preventing falls?
  • Do I know how to turn someone in bed so he or she doesn’t get bedsores?
  • Who will train me?
  • Can I begin the training in the hospital?

 5.  Questions when discharge is to a rehab is a rehab facility or nursing home:

  • How long is my relative expected to remain in the facility?
  • Who will select the facility?
  • Have I checked online resources such as the Care Quality Commission 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?

 6. 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 means for families to interact with staff?
  • Is the staff welcoming to families?

 7. Questions about medications:

  • Why is this medicine prescribed? How does it work?  How long will the medicine have to be taken?
  • How long will we know that the medicine is effective?
  • Will this medicine interact with other medications, prescription and non-prescription or herbal preparations 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 problems might I experience with the medicine? At what point should I report these problems?
  • Will I have I to 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 counselling?
  1. Questions about follow -up care:
  • What health professionals will my family member need to see and how often?
  • Have these appointments been made? If not, whom should I call to make these appointments?
  • Where will the appointment be? In the hospital, at home, somewhere else?
  • What transport arrangements need to be made?
  • How will our GP 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?

 9. Questions about finding help 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?
  1. Questions about my needs as a caregiver:
  • 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 and 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 counselling and support groups?
  • How can I get leave from my job to provide care?
  • How can I get respite (break) from care responsibilities to take care of my own healthcare and other needs?



"Rehabilitation interventions can lead to positive outcomes for children and their families if delivered in the familiar home environment and applied to everyday situations"
Cerebra; United Kingdom
"Our 10 year study proves that family-led home-based neuro-rehab interventions deliver the best outcomes for children and young people"
Lucia Braga; Brazil
"There are problems with getting people into neuro-rehab. Those most in need are often those most excluded due to a lack of socio-economic resources."
Vicki Anderson; Australia
"Brain development is complex and prolonged. Brain plasticity is influenced by a range of factors. Plasticity provides a base for neuro-rehab therapies and treatment"
Professor Bryan Kolb; Canada
"Taking brain injured children home causes high stress for families. Disjointed services exacerbate family stress levels."
Deborah Andrews; New Zealand
"Participation in teen sports and normal activities leads to improved quality of life for children and young people post brain injury and helps to maximise outcomes"
Claire Willis; Australia
"Intensive and individualized approaches work. A one-size-fits-all approach doesn't. You have to make it relevant to the child."
Recolo; United Kingdom
"More play increases brain plasticity and makes for better recovery post brain injury"
Professor Bryan Kolb; Canada
"With support parents cope better so the child has a better recovery"
Andrea Palacio-Navarro; Spain
"Strength-based family intervention after pediatric ABI is essential. Parents need to be equipped with the skills to cope and advocate for the child."
Caron Gan; Canada

OUR MISSION: To work to remove inequalities for children & young people affected by acquired brain injury; and provide effective support to their families that makes a real difference.

Council for Disabled Children Community Funded Charity Excellence Lottery Funded Youth Foundation BBC CiN