Hospitalization and Discharge Services
Annie (not her real name) suddenly started feeling light-headed, dizzy, and had difficulty walking. She called 911, was taken to the closest ER for treatment, and hospitalized with a minor stroke. Her short hospital stay was a confusing whirlwind of medications, tests, nurses, doctors, family, and plenty of questions. Neither Annie nor her daughter would have known where to start to make plans for her continued care and recovery, had it not been for the hospital social worker.
As Annie got closer to discharge, her doctor recommended a short stay at a skilled nursing facility. With the help of the social worker, she chose a facility close to her daughter’s home. After a discharge date was decided with her physician, she was transferred there for continued physical therapy (PT) and general conditioning and strengthening.
What happens if you are suddenly hospitalized for an acute medical reason, and you have to arrange for further care after your discharge, but you don’t know how? You may have to make these decisions within a very short time. The average length of stay for Medicare patients is five days, according to the most recent available 2014 statistics from the Centers for Medicare and Medicaid (CMS).
Your discharge plans will vary depending on your level of independence before you were hospitalized, the current severity of your illness, and the services that you will need after discharge.
So what can you expect during your hospital stay, in terms of professional help with discharge planning? Whom can you turn to if you need information about your discharge options?
Help with Discharge Planning is Available
First of all, know that there is help available. Assistance with discharge planning is available in every hospital serving Medicare patients.
There are experienced professionals at the hospital whom you can contact for help with discharge planning. The department to contact is often named Case Management, Discharge Planning or even Social Work. These professionals may be nurses or social workers who will help you navigate and coordinate your care with your physicians, other healthcare team members, and the facilities that may continue your care after discharge. They can also provide important information as to average costs, insurance coverage of services, and admission requirements of service providers.
Options for Care after Discharge from a Hospital
Here are some of the services that may be considered as options for post-discharge care:
- Short stay at a skilled care facility that will provide skilled nursing care and/or therapy services until you can return to your own home or another facility alternative (i.e., assisted living, intermediate care, etc.).
- Discharge home with home health nursing services which may include physical therapy or equipment needs in your home (i.e., hospital bed; commode; walker).
- Acute rehabilitation at a short term unit, often hospital-based, though not exclusively.
- Home with privately hired homemaker services or other funded (depending on requirements being met) or private live-in services.
- Palliative or hospice care.
Remember, for the above services, other than homemaker and live-in’s, you must meet medical criteria for eligibility. A good reference is published by CMS and is available on www.cms.gov under “Discharge Planning.” And call on a Case Manager to lead you through the maze!
After Annie spent three weeks at the skilled nursing facility, she was stronger and able to be discharged home. Home health services were arranged by the facility’s social worker so she could receive continued PT in her own home. And in order to make life easier for her, Annie will receive home delivered meals until she is more independent. Both Annie and her daughter were so relieved that all the services she needed were arranged and in place when she returned to her own home.
- 2015 CMS Statistics (US Department of Health and Human Services: Page 37, Table IV.3
- “Your Right to Hospital Discharge Planning Services”. Hospital Services: Part A. www.medicareinteractive.org
- Discharge Planning: Medicare Learning Network, Department of Health and Human Services Centers for Medicare and Medicaid. www.cms.gov