Discharge planning starts on the day you are admitted, not the day you leave. Most preventable readmissions happen because something in the plan was unclear, incomplete, or missed at the transition home. Medicare requires hospitals to give you a written discharge plan.
What a good discharge plan includes
- Written summary of your diagnosis and hospital course
- Complete, reconciled medication list (what to start, stop, and continue)
- Follow-up appointments with dates, times, and phone numbers
- Home care instructions: wound care, activity limits, diet
- Warning signs that mean call the doctor or go back to the ER
- Equipment ordered (walker, oxygen, hospital bed) with delivery details
- Home health, physical therapy, or hospice referrals if needed
Questions to ask before you leave
- What is my diagnosis in plain language?
- Which of my old medications should I stop?
- Who is my point of contact if something goes wrong tonight?
- When will I see my primary care doctor?
- What symptoms mean I need to call 911 vs. call the doctor?
Common pitfalls to avoid
- Duplicate medications (a new prescription plus an old one for the same thing)
- Missing durable medical equipment on the day of discharge
- No follow-up appointment scheduled before you leave
- Discharge instructions only given verbally
Your rights
- You can request a copy of your discharge summary at any time
- If you disagree with the discharge decision, Medicare beneficiaries can request an immediate review from the Quality Improvement Organization (QIO) before leaving
- You can bring a family member or advocate to the discharge conversation
Key takeaways
- Ask for the written plan the day before discharge, not at the door
- Reconcile every medication out loud with a nurse or pharmacist
- Confirm the follow-up appointment is scheduled and on your calendar
- Know exactly who to call after hours
Source: Medicare.gov — Discharge planning.