Discharge Planning

Discharge Planning

We locate the facility, explain the discharge procedure, and communicate with social workers on your behalf.

    • Evaluation of the patient is performed by an RN along with Certified Assisted Living Managers.
    • Discussion with the patient or his representative
    • Planning for homecoming or transfer to another care facility
    • Determining whether caregiver training or other support is needed
    • Referrals to a home care agency and/or appropriate support organizations in the community
    • Arranging for follow-up appointments or tests

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation, and chores; and possibly a referral to home care services.

Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care.

What should the discharge plan include?

The discharge process and plan should address the following items:
• Your loved one’s condition and any likely problems or changes that could occur at home;
• A determination of Medicare or insurance eligibility for the recommended discharge services, e.g., rehabilitation, skilled nursing, home health, adult day services;
• Establishment of home care services, and necessary equipment rentals or home modifications;
• Referral to community-based services, e.g., adult day services or case management to help coordinate and manage post-discharge services;
• A review of all medications taken prior to admission and all the medications prescribed to be taken post discharge to ensure no duplications, omissions or harmful side effects;
• A complete written medication list with dosage instructions;
• The teaching and practicing of specific patient care procedures;
• Dates and times of follow-up appointments;
• A 24-hour phone number for the caregiver to call to speak with a health care professional regarding any health and care-related concerns; and
• Transportation home.

We are Here to Help

Senior Care Placement Testimonials

Senior Care Placement is  awesome!  As a Social Worker in a high pace Skilled Nursing Care facility, planning safe discharges can become very challenging.  Just when things get over whelming and I encounter difficult discharges, Ms. Mary from Senior Care Placement is always available to lend a helping hand.  Ms. Mary meets with our patients and answers all questions and concerns patients have about returning to the community. She gets to know the patients in order to recommend the best Assisted Livings to fit the patient's needs. Ms. Mary is not all talk.  After she meets with the patients she makes arrangements and provides transportation to take them out to see Assisted Livings of their choice. This is very important and helpful to me because I don't always have time to take patient's out in the community to see Assisted Livings. I highly recommend Senior Care Placement! I am very thankful and blessed to have Senior Care Placement!!!

J. House – Social Services 

My name is Bettiejoe Davis and I worked with adult with disabilities for over 25 years. I managed our group homes and worked and also worked as an assisted living management on the side. One day I decided to step out on faith and open my own.  I took some classes but nothing prepares you for real life.   I did not know how to get clients.  I came across Senior Care Placement.  The staff was so professional.  I felt at ease talking with them.  It was if we knew each other for years.  Fast forward,  three years later, I am still in business and Senior Care keeps all my beds full.  Thank you for all you do.  I could not have done it with out you.

Bettiejoe Davis – Group Home Manager

Mrs. Mary and Antionette are very professional, knowledgeable, warm and welcoming women. The level of service I've experienced by working with them is Top-notch. I have two wonderful residents that I have acquired by using Senior Care and I am pleased to say they have worked out successfully. It is always a smooth, pleasant experience from beginning to end! Thank you for everything you do. I look forward to continuing to work with you.

J.Weston – Baltimore Provider