Before You Go To the Hospital -
Plan for Coming Home

Preparing for a hospital procedure or stay in an acute care hospital can be a very confusing experience. There are many things you should ask about in advance. In addition to discussing the specific medical procedure with your doctor, it is also important to take charge of your hospital discharge planning before you are in the hospital.

That means talking with your doctor or a hospital discharge planner, sometimes called the continuing care case manager. A discharge planner is a nurse or social worker employed by the hospital to help you and your family decide the most appropriate setting for care following a hospital stay. If you are a member of a managed care plan or HMO, the plan has case managers who will work with you. After your hospital stay, you may be able to go home, or you may need to go to an aftercare facility such as a rehabilitation hospital or nursing home. Ask the discharge planner to explain the range of options you have and whether your insurance will pay for the services you choose.

PLAN AHEAD: Here are some questions you should ask your doctor before you go into the hospital:

  • Will I need skilled nursing or therapy services?
  • When will I be able to resume normal activities?
  • Should I arrange for a ride home, or for transportation during my recovery?
  • Will I need someone to stay with me during my recovery?
  • Will I need help with bathing, dressing or toileting when I arrive home?
  • Will I need help buying groceries or preparing meals?
  • Will I need help with housekeeping or yard work?
  • Will I need help coping with my operation, illness or recovery?
  • Will I need to go to a rehabilitation center or nursing home? May I choose the center?
  • Will my insurance pay for my procedure and aftercare needs?
  • Are there community programs that provide these services or help pay for these services?

Now You Are In the Hospital -
Involve Yourself in Your Discharge Planning

If you did not have time to plan before you enter an acute care hospital, you still have the opportunity to participate fully in your discharge plan. Ask to speak with the discharge planner. Any patient of any age can ask the discharge planner to evaluate their need for discharge planning.

If you need continuing care, your doctor, nurse, and discharge planner will work with you and your family to develop a special plan to meet your needs. Share with the discharge planner any concerns you have about your ability to manage your own personal care, your medications, housekeeping, caregiving duties, mobility, and recovery needs once you are at home.

If you need continuing care services, the hospital discharge planner must give you a written discharge plan before you leave the hospital. Special Rule: In Massachusetts, if you are a Medicare beneficiary leaving an acute care hospital , then the hospital usually must give you the written plan 24 hours before you leave the hospital.

The discharge plan must contain information on:

  1. the continuing care services you need, including medical treatments, medical transportation, and homemaker services
  2. detailed information about the services that have been arranged
  3. names, addresses and phone numbers of the service providers
  4. a schedule outlining when nursing, therapeutic or custodial care services will begin
  5. medications you will need and instructions on their use
  6. information about special diets and treatments
  7. the schedule for any of your follow-up medical appointments.

If you are told by hospital staff that you are ready for discharge, but you have not yet received a written discharge plan, ask for it. You must sign the plan to indicate you received the plan. This signature does not mean you agree that the plan is appropriate for you.

In some cases, you may not agree with the discharge plan. For example, you may think the plan does not arrange for all the services that you will need at home, or your family caregiver will not be able to help you as you originally thought. If you are dissatisfied with your discharge plan, immediately notify the discharge planner. Talk with the discharge
planner and your doctor about your concerns. If you still are not satisfied, then you may contact the Massachusetts Department of Public Health, Division of Health Care Quality at 1-800-462-5540.

Special Rule: In Massachusetts, if you are a Medicare beneficiary and you are dissatisfied with your written discharge plan, then you have the right to a formal appeal.

Steps for a Medicare Discharge Planning Appeal:

  1. Tell the discharge planner immediately, while you are still in the hospital, that you do not agree with the plan.
  2. She/he must arrange a meeting with you and try to develop a plan that is acceptable.
  3. If you are still dissatisfied, you have the right to appeal to the Advocacy Office of the Massachusetts Department of Public Health.
  4. Contact the Advocacy Office at 1-800-462-5540 or 617-753-8150 by noon of the first day after you receive your discharge plan. They will work with you and the hospital to resolve your problems if at all possible.

A different problem occurs when you feel that you are not medically ready to be sent home. If this happens, you should contact your discharge planner and doctor immediately. Special Rule: If you are a Medicare beneficiary and you feel you are not ready for discharge, then ask for a written “Notice of Non-Coverage.” Call MassPRO to request an immediate review of the notice. You must call MassPRO at 1-800-252-5533 by noon of MassPRO’s first business day after receiving the written notice to receive an immediate review.

At Last! You Are Home

Once home, you still may have many questions about your care, either your medical needs or in-home services. There may be several agencies or health care professionals (doctors, nurses, therapists) involved in delivering the care you need. The hospital’s discharge plan that you received lists these agencies and/or health professionals. It is important to know the names, addresses, and telephone numbers of those who will be working with you. Refer to this list when you need to speak to someone about your care.

Do not hesitate to call your doctor, nurse, discharge planner or managed care case manager whenever you have questions about your recovery, discharge plan, or when there are problems with the services being provided. Ask them to help you resolve the problem.


Take charge of your hospital discharge

Presented in cooperation with:

The Massachusetts Department of Public Health

For copies of this Alert, contact
MDPH Elder Health Programs at
617-624-5405

This Elder Health Alert was prepared in conjunction with the Discharge Planning Committee of the Massachusetts Beneficiary Services Work Group, a coalition of state and federal agencies organized by the Health Care Financing Administration to improve beneficiary services for Medicare and Medicaid beneficiaries. The committee is co-chaired by staff from the Executive Office of Elder Affairs and the Department of Public Health and was established to study discharge planning systems and patient rights to discharge plans. Part of the committee’s work is to increase patients’ awareness of their rights to comprehensive and individualized discharge plans.