September 1, 2023
Reading Time 4 min.

From Confusion to Clarity: A Caregiver's Guide to Hospital Discharge Queries

Last week we started looking at the hospital discharge process and what potential discharge destinations would be. You can find that post here. Today we take a look at who, how and when to ask questions regarding discharging from acute care and when to follow up. 

Who do I ask about the discharge plan? 

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Depending on the hospital or facility, the case manager or social worker would be a great resource. You can ask the nursing staff who you should speak to regarding discharge planning and they will be able to point you in the right direction.

The case manager or social worker who is assigned to your loved one is a great resource when navigating the transition from acute care to the next level of care.

Their role is to gather information from the medical staff (doctors nursing and rehab) and insurance to understand what services will be covered upon transition to the next level of care.  

How should I ask about the discharge plan?

When I am stressed out, I can be quite demanding and forget that other people are juggling as many or more responsibilities and priorities as I am.

Taking a step back and remembering to treat everyone I interact with with respect and understanding helps me be less demanding. That being said, it is important to begin the conversation.

Here is how to go about it:

  • Find out who to speak to regarding discharge planning and ask the best way to contact them. 
  • Leave them a message or send an email. State who you are, your relationship to the patient and ask to schedule a time for a brief conversation regarding discharge planning. Make sure to tell them how to get back in touch with you if you are leaving a message.
  • When a time is set to have this conversation, get out the notepad and write down your most important questions. Try to keep this list short as you will have an opportunity to follow up on the first conversation.
  • Time for the meeting. Ask your questions and take notes regarding their responses. Be considerate of their time as they likely have many of these meetings to work through.
  • As the meeting is wrapping up, thank them for their time. A little gratitude goes a long way and shows that you understand they are busy and that their time is valuable. 
  • Ask them the best way to reach out if you have any additional questions. Make a note of their response and use their preferred form of communication for following up. 

When should I ask about the discharge plan or options?

woman in white tank top and blue denim jeans holding woman in blue long sleeve shirt

The time to start asking about the discharge options is as soon as you can. For patients whose discharge level is not yet determined, or may be between two options, it is still a good idea to begin learning what the options are.

This will provide the greatest likelihood of the best outcome. There may be multiple good options available that would require visiting each and comparing.

There may not be many good options close by causing the search to have to be widened and more time spent visiting the facilities.

There are good and bad rehab centers just like anything else. During my time as a PT, I have seen both. I have worked in a couple of nursing homes that I would not let my family ever stay in. Others are very clean with friendly staff and plenty of support for patients.

You can usually tell during a short visit to the facility. If you take a look at 3 facilities, you will likely begin to see differences between good and bad. You will be better able to identify a quality facility.

What should I do if I haven't heard back from them in a few days?

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It is OK to reach out and check in, but know that the most likely scenario is that there is just no news yet.

It could be that your loved ones medical status and functional ability have not yet reached a point where the next level of care is known. It may be that the next level of care has been determined and the case manager has reached out to other facilities to see who has a bed.

This takes some time as each facility will have to review the hospital documentation and determine if the patient is a good fit. It could be that they have been meaning to reach back out, but have not had a spare moment as they have been putting out fire after fire for days. The important thing to know is that discharge won’t just happen without the patient and caregiver knowing the expected plan.

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Here is a great example of a success story I observed when I previously worked at Walton Rehab Hospital in Augusta, Georgia. It shows effective vs. non-effective communication with staff.

An elderly woman was undergoing rehab following an extensive surgery. Her large family filled the sitting area with tension, asking therapists, doctors, nurses, dietitians , case managers and even cleaning staff incessant questions and unintentionally causing disruptions. Craig, a transporter, saw the situation and decided to do what he could to help instead of ignoring it and going about his job.

He took it upon himself to bring the family coffee and ask them about themselves. Asking plenty of nonmedical questions to ease their minds. Craig can talk for days about fishing, but he did a great job of letting the family members talk through a lot of their anxiety however they needed to. This allowed the family to trust him and he was able to explain that the medical team at this hospital was top notch and that it would be best to let them focus on their work.

The family's demeanor changed. They became less demanding and more supportive. In turn the staff was able to focus more on their job at hand and find time to answer the families questions when they had more information. This example shows that when stress is reduced and communication is improved, the outcomes are better for all involved parties.

That's all for today.

Take care, keep mom safe at home and have a great day!


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