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What a discharge planner does, and what to ask before you leave
Somewhere in the last day of a hospital stay a person appears with a lot of questions about home. That is the discharge planner, and the twenty minutes with them are the most useful twenty minutes of the whole stay.
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Who they are
Usually a nurse or a social worker, often with the title case manager. Their job is a safe discharge: arranging home health visits, equipment, a short rehabilitation stay if one is needed, transport, and the follow-up. They know which local services exist and how to get them started, which is knowledge a family otherwise acquires the hard way.
Ask for them early
You do not have to wait to be found. Asking a nurse on the first day to have case management come by means the planning starts with days in hand rather than hours, and it means you are in the room when it happens.
What to ask
- What changed in the medicines, and who is reconciling them with what was already at home
- Which follow-up appointments are needed, and who books them
- What equipment is coming, when, and whether the house is ready for it
- Whether home health visits are arranged, starting when, and who pays
- Who to call if something goes wrong after five o’clock, with the number
- Whether the discharge summary is going to the family doctor, and whether you can have a copy
Say what home actually looks like
Stairs, who else is in the house, who is cooking, whether anyone can drive. The plan is only as good as the picture the planner has, and families understate the difficulties out of loyalty. If home is not safe yet, say so; a short rehabilitation stay is sometimes the answer, and it is not a failure.
In writing before you leave
The discharge summary, the medication list as it now stands, the follow-up dates, the contact numbers, and when the equipment arrives. If you do not have those, you are not ready to leave, however keen everyone is to go.