Hospitals are designed to provide acute care and treatment. A process known as hospital discharge planning will help explain what care, services, and treatments are needed to successfully transition back into the community after a hospital admission. All Medicare beneficiaries are entitled to take part in the hospital discharge planning process.

How Does the Hospital Discharge Planning Process Begin?

Every hospital has different policies for how to handle discharge planning. However, most hospitals will start the discharge planning process as soon as your doctor has determined that there is no longer a need for care.

Once your doctor has determined you no longer need care, the hospital will appoint someone to work with you on discharge planning. This individual is usually a social worker but may be a specialty discharge planner or nurse.

The discharge planner will contact you and inform you of the upcoming discharge. The planner will discuss with you your doctor’s recommendation on whether you may return home or if it is recommended that you receive additional care at a specialized facility or rehabilitation center.

What is an Important Message from Medicare or an IM/IMM?

Even if the discharge planner informs you verbally that you are ready for discharge, it is not considered official until you receive written notice. When you are ready for discharge, the facility will provide you with a signed copy of the Important Message from Medicare.

The Important Message from Medicare outlines your rights and protections regarding your hospital discharge. It explains the appeals process and how to start it should you disagree with the discharge.

The Important Message from Medicare is typically given to you no more than 2 days before your date of discharge. If the hospital feels that you are unable to take part in the discharge planning process, they are required to provide a representative or agent of your choosing with this letter.

It is important to note that the Important Message from Medicare is only given if you have been admitted to the hospital for more than three days. If your hospital stay was shorter, you will not receive this letter.

What Should Occur During the Discharge Planning Process?

The discharge planning process is designed to make sure you receive continual care and treatment for your injury or illness after you have left the hospital. As part of the discharge planning process, the following things should occur:

  • Discharge planner and care team works with you to educate you on your illness and/or injury.
  • Discharge planner and care team will explain to you any care or treatment that will be needed after discharge.
  • A list of specialists or individuals to contact with questions after discharge should be provided to you.
  • Discharge planner will work with any outside providers, such as primary care doctors or specialists, to make sure follow-up care is provided and that all appropriate information is sent.

What Information Should All Hospital Discharge Planning Plans Include?

Even though the hospital discharge planning process varies from facility to facility, there is still basic information that every Medicare beneficiary should receive as part of the discharge process, which may include the following:

  • Information on the patient’s health – this includes a summary of any health conditions, an overview of the care provided at the facility, strategies, and suggestions on how to improve your health, and a list of symptoms or signs to watch for that could indicate a problem.
  • Care for after discharge – this will include proposed follow-up care and treatment as well as provide clarification on whether you are returning home or entering a rehabilitation center. It will also provide you with the name of the provider who you should schedule follow-up care with or make an appointment.
  • Medication list – a detailed list of all medications that you are taking should be provided. This includes any new medications that you were given for your condition or injury. It also outlines current prescription medications, over-the-counter medications, and supplements. This list will detail all instructions for this medication including when and how much you should be taking.
  • Additional aids – if additional equipment or support is needed, such as walkers or wheelchairs, this information is provided here.
  • Skill training – this outlines any specific actions or procedures you will need to perform to continue your care. Examples of skills that may be covered in this section include how to change a bandage, how to properly wrap an injury, how often to apply ice or when and how to administer injections.
  • Recovery and support – this provides a list of basic activities of daily living, such as bathing, walking, lifting, and driving, and indicates whether you can complete these tasks independently or if you need assistance.
  • Hospital information – who to contact with any questions regarding your care.
  • Follow-up appointments – information about any follow-up appointments that have been scheduled for you during your hospital stay.

Successful hospital discharge planning will not only help you transition back into the community, but it can reduce your risk for readmission as you know how to properly care for or manage your injury or illness.