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.

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Senior Care Placement Testimonials

I was wrestling with trying to provide at-home care for my mom, now 93, when it became clear that I could not handle it and she was scheduled to be released from a rehab facility. The caseworker referred me to Senior Care Placement and they moved swiftly to help me identify a place that has truly become a second home. My mom is not only well-cared for, but loved and treated like a family member. My mother adapted quickly and gone from someone disinterested in life and seemingly headed to an end-care stage to regaining a healthy appetite and interacting with people as best she can. Antoinette made the transition as seamless as possible. I recommend them to anyone looking for assistance with a loved one. 

Jackie Jones

My father, a 75 year old with dementia was dumped at a hospital emergency by his assisted living home while I was out of town. While I tried everything I could to place him in emergency short term care; he stayed in the emergency room for three days. Senior Care Placement was able to find an assisted living that would take my father until I was able to come back to town. Miss Wilson helped me personally, and I am very thankful to her and her organization.

Michael Johnson

I feel lucky to have found Serene Homestead to place her husband thanks to Senior Care Placement.

Loving Wife