At the end of your hospital stay, hospital social workers, nurses and other professionals should help you plan your care after you leave. These hospital discharge planning services intend to make your move from the hospital to your home or other location as smooth and safe as possible. Hospital discharge services also aim to prevent additional trips to the hospital for you.

Medicare requires hospitals to follow specific rules for delivering you these discharge planning services. However, these requirements only apply if you are admitted to the hospital as an inpatient. If you are considered a hospital outpatient and have observation status, Medicare does not require hospital staff to help you prepare for your care following a hospital stay. Some states may provide you with greater rights to discharge planning services. For more information on discharge planning in your state, please contact your State Health Insurance Assistance Program (SHIP). You can find the contact information for your SHIP by visiting www.shiptacanter.org.

Read below for more information about your rights to discharge planning and steps you can take to ensure you leave the hospital with a good, complete, and practical plan for your care.

  1. You or your doctor should ask hospital staff for a discharge planning evaluation.  A discharge planning evaluation tries to foresee your medical and other care needs after your hospital stay. Some hospitals automatically evaluate the discharge needs of all patients and some do not. But, if you or your doctor ask for a discharge evaluation, the hospital must give you one.
  2. Be aware that the hospital’s main goal during your evaluation should be to return to you to the place you left before your hospital stay (this may be your home or another facility). If this isn’t possible, the hospital should recommend other, more appropriate places for you.
  3. Make sure hospital staff considers the range of the needs that you have following your hospitalization. If you are going back home, the discharge planning evaluation should see whether you can care for yourself or will need assistance from family, friends or other community caregivers. For example, do you need home health care or meal delivery services? The hospital staff should also see whether you will need medical equipment or changes to your home to make it safe.  If you are going back to a facility, the hospital must make sure the facility can still care for you after your hospital stay.
  4. Review which post-discharge services will be covered by Medicare and how much they will cost. If you have another type of insurance, such as Medicaid, check what is covered by that insurance. The hospital should be aware of what Medicare does and does not cover and should tell you when costs may apply. The hospital should also be familiar with Medicaid and options for coverage, such as home attendant care and long-term care services.
  5. Tell the hospital discharge planning staff about your needs and preferences.  The hospital must reach out to or your representatives and, if possible, incorporate your wishes into your discharge plan. After the hospital finishes the evaluation, it should review the results with you and get your feedback before drawing up a final plan for your care.
  6. Be sure the hospital prepares you for discharge. Before you leave the hospital, staff must educate and train you, your family or your caregivers about your care needs. Hospital staff should also provide a clear list of instructions for your care and all medications you will need. The hospital must explain what to do if problems occur, including who to call and when to seek emergency help. The hospital must arrange all referrals for other care, including referrals to home health, skilled nursing or hospice agencies, physicians, and medical equipment suppliers. They should also put you in touch with community services that help with financial assistance, transportation, meal preparation and other needs.  The hospital is required to provide you with a list of home health agencies or skilled nursing facilities in your area that participate in Medicare and to assess your need for hospice care.
  7. Follow up with your primary care provider and other providers involved in your care. Hospital staff should advise you to schedule a follow-up visit with your primary care and other providers soon after your discharge. Some hospitals even help you schedule these follow-up appointments. Regardless, the hospital should send your providers information about your medical condition no later than 7 days after you leave the hospital. Keep in mind that Medicare now pays for your primary care provider to manage your care right after your hospital discharge.