This is part 2 of my series on how to prepare to go home after a hospital discharge. Click here for Part 1.

Being in the hospital is tough on the patient. If you are in the hospital for a few days, you should expect that your functional abilities will decline. When you return home there is a good chance you will need assistance and supportive care for a while. But, you will no longer have the professional care support that was available to you when you were in the hospital. You may qualify for some limited licensed home health services. But most or all of your care needs will have to be met by your non-professional family caregivers. Hopefully, your family will be prepared.

Recently I wrote about the importance of advance preparation by caregivers when a loved one is being discharged from a hospital. See Preparing for your Hospital Discharge. As I noted, one way your family can prepare is by taking full advantage of the support that should be available from the hospital in conformity with the new Pennsylvania CARE Act.

This article provides some additional information on what you can do to prepare for a hospital discharge. Better preparation can improve the post-hospital quality of care, reduce the likelihood of re-admission, and limit the physical and emotional stress on caregivers.

Medicare Discharge Requirements

Medicare regulations require hospitals to follow rules to help you with your discharge and make your transition home safe. These discharge planning rules only apply if you are considered a hospital inpatient. (They do not apply if you are an outpatient or on observation status).

The hospital must provide a discharge planning evaluation to all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning, and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician. A nurse, social worker, or other appropriately qualified personnel normally will develop the evaluation.  A discharge plan must be developed if the evaluation indicates it is needed or if the patient’s physician requests it. (42 CFR 482.43(c)).

CARE Act Requirements

In addition to the Medicare rules, the Pennsylvania CARE Act requires hospitals to provide discharge planning assistance when a hospital inpatient is being discharged to home. When an inpatient is to be returning to their residence, the CARE Act requires the hospital to consult with the patient’s designated lay caregiver and issue a discharge plan that describes the patient’s after-care assistance needs at the residence.

The CARE Act discharge plan also must include contact information for any health care, community resources, long-term care services and support services necessary to successfully carry out the patient’s discharge plan and contact information for a hospital employee who can respond to questions about the discharge plan. Hospitals are also to provide lay caregivers with instructions in all after-care tasks described in the discharge plan.

Questions to Ask

When you learn that a discharge is planned, find out who the hospital has assigned as your “discharge planner.” Recognize that the patient and family home caregiver are critically important members of the discharge planning team. This should be an interactive process. Be prepared to ask lots of questions to get the guidance and assistance you need. Express your concerns. Take notes. Try to have another person (e.g. another family member or friend) involved in discharge planning discussions. They can help ask questions and listen to directions.

Here are some questions to consider asking prior to the discharge: 

  • Who on the hospital staff will assist with the discharge planning?
  • When will the discharge take place?
  • How will the patient get home safely?
  • What equipment and supplies will be needed? How can they best be obtained?
  • What patient care procedures will the home caregivers need to perform?  Do the caregivers have the physical ability and knowledge needed to perform them?
  • How can the home caregivers get the training, practice and support they need to be able to perform required tasks and procedures?
  • What special foods and diet will the patient require?
  • What medications will be required? Will the caregiver require training in administering medications?
  • What changes in condition or other problems might occur at home? How should the patient and caregivers respond if problems arise?
  • What resources will be available to provide respite time for the home caregivers?
  • What follow up care will be needed? When is the first follow-up appointment?
  • Who can the patient and/or caregivers call with questions and concerns?
  • Will professional in-home assistance (such as physical therapy or occupational therapy) be needed? Who will arrange for those services?
  • What costs will be encountered and how will they be paid (e.g. Medicare, Medicaid. VA benefits, out of pocket)?

Additional tips on preparing for a hospital discharge to home are available online. The Medicare website includes a planning checklist: Your Discharge Planning Checklist [opens as a .pdf file]. I suggest that the patient and/or primary caregiver print out this Medicare booklet and take it with you to the hospital.

Another helpful checklist is Going Home: What you need to know

The Next Step in Care website has wonderful resources for patients, caregivers and providers.

Visit to learn about home health services.

The law firm of
Marshall, Parker & Weber, LLC has offices in Williamsport, Wilkes-Barre, Jersey Shore and
Scranton. For more information visit or call 1-800-401-4552.

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