All hospitals must have services available to help patients plan for their discharge (when they leave the hospital). These discharge planning services are intended to identify an individuals’ need for medical and social services after they leave the hospital and to help prevent the need for re-hospitalization.
You have the right to ask for an evaluation to determine if you need help planning for discharge. If your doctor requests a discharge plan, the hospital must provide it. In some states you may have the right to additional services.
The discharge planning evaluation must be done by a nurse, social worker, or other qualified professional with discharge planning experience.
If you will require skilled care after you leave the hospital, such as physical therapy or a nurse to monitor your condition, you will most likely require a discharge plan.
If the hospital evaluation determines you need a discharge plan, or if your physician requests a discharge plan for you, the discharge plan must involve:
- input from you and your representatives about your preferences and care needs after hospitalization;
- information and instructions to you and your caregivers about post-hospitalization care you need;
- arrangement of necessary post-hospital services and transfers and referrals to appropriate services and facilities.
For example, if you had hip-replacement surgery and need skilled therapy care after your hospitalization, the hospital should work with you to decide the most appropriate setting for you to receive the care you need. Depending on your needs, the hospital must provide you with a list of Medicare-participating skilled nursing facilities or home health agencies in your area. The hospital should contact you (or your representatives) and caregivers and transfer your medical information to the providers of your choice.