What You Can Do to Help - For Discharge Planners

Discharge PlanningThe hospital door is a revolving one for many patients.  About 20% of Medicare patients will be readmitted to the hospital within 30 days.  That’s unfortunate for patients and families, costly for hospitals, and harmful to a home health agency’s performance metrics.


Hospital stays have become shorter and patients are older and sicker.  Many patients are discharged before they feel ready.  Patients and families are often confused.  Caseloads are high.  The pressure to avoid readmission is real.  Yet appropriate discharge planning remains essential to the orderly function of the hospital, the ongoing care of patients, and the well-being of family caregivers.

We hope our home care directory and companion materials help you do your job.  If we can be of further assistance please contact Sara Ratcliffe, Executive Director, Illinois HomeCare & Hospice Council at 217-753-4422.


The Illinois Caregiver Advise, Record and Enable Act (IL CARE Act) (effective 1-27-16) recognizes the vital role caregivers play in after-care and requires hospital staff to identify and consult with the caregiver. It requires discharge planners to issue a discharge plan describing the patient’s after-care needs at the patient’s residence. You will find the IL CARE Act here.

At a minimum, the discharge plan shall include:

  • A description of the after-care assistance tasks deemed appropriate by the discharging physician or other health care professional
  • Contact information for any health care, clinical community resources, and long-term services that may be helpful in carrying out the patient’s discharge plan.
  • Contact information for an individual designated by the hospital who can respond to questions about the discharge plan.

The hospital must also make an effort to provide or arrange for the designated caregiver to receive instructions in after-care assistance as described in the discharge plan.

At a minimum, the instruction provided by the hospital to the designated caregiver shall include:

  • A live or recorded demonstration of the after-care tasks in a culturally-competent manner.
  • An opportunity for the caregiver to ask questions about the after-care tasks.
  • Answers provided in a culturally competent manner and in compliance with state and federal law



There are many online resources to aid discharge planners as they assist patients and caregivers through the discharge process, including:

A particularly helpful tool is What Do I Need as a Family Caregiver? The second phase of the project, Next Step in Care, links to easy to use guides and videos aimed at caregivers and health care providers. If you want to review your entire transition process, one excellent resource is Engaging Family Caregivers as Partners in Transitions, a special report from the United Hospital Fund, based in New York - click to download below.


Preparing patients and caregivers is only one part of a safe and effective transition.   During the critical transition time, clear communication must ALSO occur with post-acute care providers.  And family caregivers are most in need of an ideal transfer when the patient is transitioning to home -- where caregivers can quickly become overwhelmed and home health professionals may arrive the day of discharge (or soon after) with inadequate information about the diagnosis, medications, equipment needs or even the name of the referring physician.

In some cases, patients have not answered the door because they were unaware that home care had been ordered, or home health professionals found themselves knocking on the door to an empty house, unaware that the patient was recovering at the home of a family member.  These situations put patients at risk of readmission and can cause lingering anger and frustration.


When the Illinois Health and Hospital Association and the Illinois HomeCare and Hospice Council presented a joint discharge webinar to their members, the following actions were identified as key to a successful transition.

  • Provide thorough hand-off communication/transition of care (H&P, Med list, dc instructions, correct physician)
  • Provide complete, accurate discharge instructions (preferably 24 hours or more in advance)
  • Set appropriate expectations with the patient regarding home care services and caregiver responsibilities
  • Assure (to the best of your ability) that the patient is going to the appropriate level of care
  • Be realistic when describing patient needs upon referral (for example,  if the patient has required 2 nurses to perform wound care inpatient, they will likely require the same at home)
  • Be realistic about whether the patient is stable and strong enough to be transferred home.  Sometimes returning home just isn’t possible.
  • Understand that attempting to transfer to hospice home care in the last hours may pull the family from the bedside at a critical time, without a discernable benefit. Hospice professionals can support an actively dying patient and family at the bedside without the transfer distraction. Of course, when given time, Hospice can bring together medical care, pain management and emotional and spiritual support at home for not only patients but their families.
  • Closing the loop (Engage in post-discharge communication with the family caregiver and the home health agency.)

The Illinois HomeCare and Hospice Council’s Best Practices Committee has identified the following critical elements required for a smooth transition to home care services:

  1. Projected discharge date and insurance information for preauthorization and verification
  2. Home address in which care will be provided.
  3. Patient and Caregiver contact information.
  4. Name/contact for referring physician and physicians who will be managing the patient’s care at home/signing the home plan of treatment. 
  5. Order for services including disciplines (Visiting Nurse, Physical/Speech/ Occupational Therapy, Home Health Aide, Social Work), labs, treatments (wound care, tracheostomy care, catheter care, etc.), diet, activity, etc.
  6. Completed Face to Face evaluation documented in the medical record and signed by the referring physician. 
  7. Diagnoses/surgical procedures/treatments/etc.
  8. Psychosocial elements that may impact care provided at home such as environmental concerns, pets, family issues, behaviors of patient/caregiver, etc.
  9. Date of next physician appointments/ other medical appointments
  10. Patient Centered Goals
  11. Correct Medication list
  12. Medical equipment needs (crutches, cane, walker, wheel-chair, oxygen, hospital bed, etc.)
  13. Is the patient aware of home health referral?

Advance notice is always important, particularly if the patient is being discharged on a Friday, since weekends are a challenging time to begin service.  When the discharge is done at the last minute, even the most committed discharge teams can make mistakes, forget to capture important information, or leave the patient, caregiver and home health provider inadequately prepared.


While most people would prefer to die in their own homes, many terminally ill patients still die in the hospital.  This is often due to lack of understanding of the benefits of hospice and failure of health providers to open the dialogue. 

While a discussion about hospice may be hard, these conversations can lead to better pain management, time to say goodbye, and even a longer life, due to pain relief and home comforts. Some families who do choose hospice care often do so only for the last few days of life, and later regret not having done it sooner. 

Under Medicare rules, a physician must certify that a patient is eligible for hospice.  Families usually need time to digest and consider such a recommendation.  If families are wavering, discharge planners can make a significant difference.   Thoughtful discharge planners will make themselves familiar with hospice benefits, talk to hospital spiritual counselors and practice discussing the options.

You will find various tools here and  here


If a doctor has certified the patient’s prognosis as not longer than six months, the patient is eligible for hospice. This applies to anyone of any age, with any type of illness. As with cancer patients, people with ALS, kidney disease, and Alzheimer's disease, for example, can also benefit greatly from hospice care. Alzheimer's disease, in particular, is often overlooked for hospice referral because of its slow progression. People with Alzheimer's are usually referred to hospice when they are in the final stages of the illness.

If the patient is not mentally competent or is physically unable to communicate, the decision may be made by a healthcare proxy.  If an advance directive has been filled out, the family generally knows who has been designated the healthcare proxy. In the absence of a healthcare proxy, caregivers and medical advisors should take guidance from a living will, if one exists.