Hospital Discharge Planning: A Family Caregiver Guide

The call that a hospital is ready to send your parent home can arrive before you feel ready to receive them. Hospital discharge planning is the process a hospital uses to prepare a patient for that transition, and under Medicare it is not optional: a hospital that participates in Medicare and Medicaid must run an effective discharge planning process that focuses on the patient's goals and includes the patient and their caregivers as active partners.1 Knowing what that process owes you, what your rights are as the family caregiver, and how to push back on a discharge that feels too soon is what turns a rushed handoff into a safe one.

In This Guide

• Key Takeaways
• What Hospital Discharge Planning Is
• How Hospital Discharge Planning Works Under Medicare
• Your Role and Rights as the Family Caregiver
• How to Appeal a Discharge You Think Is Too Soon
• Lining Up Post-Discharge Care
• Frequently Asked Questions
• Learn More

What Hospital Discharge Planning Is

Hospital discharge planning is the work a hospital does to prepare a patient for the move out of the hospital and into whatever comes next, whether that is home, a rehab facility, or a skilled nursing stay. Done well, it answers the questions a family is actually asking: What care does Mom need now? Who will provide it? What equipment, medications, and follow-up appointments have to be in place before she leaves? And is the plan realistic for the home she is going back to?

For a family caregiver, the important thing to understand is that this is a defined process with rules behind it, not a favor the hospital does when it has time. A discharge planner, often a nurse or social worker, is usually the person coordinating it, and you are entitled to be part of the conversation rather than handed a folder on the way out the door.

How Hospital Discharge Planning Works Under Medicare

Medicare sets the floor. Under its conditions of participation, a hospital that takes part in Medicare and Medicaid must have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and their caregivers or support persons as active partners in planning for post-discharge care.1

That process has to start early. The hospital must identify, at an early stage of the hospitalization, patients who are likely to suffer adverse health consequences after discharge without adequate planning, and it must provide a discharge planning evaluation for them, as well as for any other patient who asks, or whose representative or physician asks.1 So if you are worried and no one has raised discharge planning yet, you can request an evaluation. The evaluation goes in the medical record, and its results must be discussed with the patient or the patient's representative.1

The rules also protect your choice of what comes next. When the discharge planning evaluation shows that home health, a skilled nursing facility, or a rehab or long-term care hospital is indicated and appropriate, the hospital must include in the discharge plan a list of providers that are available to the patient, participate in Medicare, and serve your area, and must inform you of your freedom to choose among them.1 The hospital must not specify or otherwise limit the qualified providers available to your parent, and the plan must identify any home health agency or skilled nursing facility your parent is referred to in which the hospital has a disclosable financial interest.1 If your parent is enrolled in a managed care plan, the hospital must tell you to check which providers are in the plan's network and share any network information it has.1

The hospital must also help patients and their families choose a post-acute provider by using and sharing data on those providers' quality measures and resource use, relevant to the patient's goals of care and treatment preferences.1 CMS says that data includes measures such as the number of pressure ulcers in a given facility, the proportion of falls that lead to injury, and the number of readmissions back to the hospital, so ask the discharge planner to walk you through it.1

Your Role and Rights as the Family Caregiver

Medicare's rules are the federal floor. Your state may add its own protections for family caregivers, sometimes through a law called a CARE Act, short for Caregiver Advise, Record, Enable. Because any such law is state law and the details vary, ask the discharge planner directly whether your state has one, whether you can be recorded as the designated caregiver, and what instruction you will get before discharge. Either way, ask for a hands-on walk-through of any care tasks you will handle at home, such as wound care, injections, or managing a new medication schedule, rather than being left to figure them out alone.

Medicare's discharge planning rules already require the hospital to include the patient's caregivers as active partners in planning for post-discharge care.1 That means you are within your rights to ask questions, request the evaluation, and say plainly when a plan will not work at home. If you are coordinating from another city, our guide to long-distance caregiving covers how to stay in the loop when you cannot be at the bedside.

How to Appeal a Discharge You Think Is Too Soon

Sometimes the plan is not the problem; the timing is. If you believe your parent is being sent home before it is safe, you have a specific, time-sensitive right to challenge it.

The key document is the Important Message from Medicare (often called the IM). Hospitals are required to deliver this notice to every Medicare inpatient, and the notice informs them of their hospital discharge appeal rights.2 Medicare says you should get the Important Message within 2 days of admission and prior to discharge.2 If no one has handed you this notice, ask for it, because it contains the phone number you need.

Here is how the fast appeal works:

1. Read the Important Message from Medicare. It explains that if you think services are ending too soon, you can ask for a fast appeal, and it lists the contact information for the independent reviewer, a Beneficiary and Family Centered Care-Quality Improvement Organization, or BFCC-QIO.2
2. Contact the BFCC-QIO by the scheduled discharge day. Follow the directions on the notice no later than the day your parent is scheduled to be discharged.2 Your parent, or their representative, can make the request in writing or by telephone.2 Meeting this deadline is what protects you financially.
3. Stay in the hospital while the review happens. If you request the appeal within that time frame, your parent can remain in the hospital while waiting for the BFCC-QIO's decision, and will not have to pay hospital charges, except for any applicable coinsurance or deductibles, through noon of the day after the BFCC-QIO gives its decision. Inpatient services after noon of that day may be yours to pay.2
4. Get the reasons in writing. Once you request an appeal, the hospital gives a Detailed Notice of Discharge that explains the specific reasons for the discharge, by noon of the day after the BFCC-QIO notifies the hospital.2 The BFCC-QIO, an independent reviewer, then decides whether covered services should continue.2

An appeal does not guarantee more days in the hospital, but it forces an independent look at whether the discharge is truly appropriate, and the burden of proof rests with the hospital to show that discharge is the correct decision.2 If you miss the deadline, you can still ask the BFCC-QIO to review the case, but different rules and time frames apply, and you might be responsible for the cost of the stay past the original day the hospital tries to discharge your parent.2 Even when an appeal is not the right move, raising a safety concern with the discharge planner and the attending physician is always fair, and often changes the plan.

Lining Up Post-Discharge Care

A safe discharge depends less on the hospital than on what is waiting at home, and those pieces take time to arrange. Start before discharge day.

• Decide who provides hands-on care. If your parent needs help with everyday activities such as bathing, dressing, using the toilet, eating, or moving around, the National Institute on Aging notes that a relative, friend, or trained aide could help for a short time each day.3 Home health care can help with medications, wound care, medical equipment, or physical therapy, but Medicare has limited coverage of home health service costs: the services must be short-term and provided by agencies certified by Medicare.3 If you can control not only what work is done but how it is done, the IRS treats the worker as your household employee, even if you hired the worker through an agency or from a list an agency provided. If an agency provides the worker and controls what work is done and how it is done, the worker is not your employee.3 Our guide to hiring in-home help walks through the options.
• Consider a care coordinator for a complex situation. A geriatric care manager, usually a licensed nurse or social worker, can assess needs, build a care plan, and find services in the community, which is especially useful when the discharge is complicated or you live far away.4
• Confirm the practical details before the ride home. Make sure you leave with a written discharge plan, a clear medication list, any needed equipment (a walker, a shower chair, oxygen), follow-up appointments, and a phone number to call with questions. Medicare's rules entitle you to be part of building this plan, so do not accept vague answers.
• Find local help you may not know exists. The Eldercare Locator, a free, nationwide service of the Administration for Community Living, connects families to services in their community, including the local Area Agency on Aging, in-home help, and transportation, and can be reached at 1-800-677-1116.5

If this is your first time coordinating a parent's care, our getting started guide for family caregivers covers the wider picture beyond the hospital stay.

Learn More

Find personalized help planning a safe hospital discharge for an aging parent at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.