Hospital Discharge Planning (Notes from caregiver conference)

Brain Support Network volunteer Denise Dagan attended the Avenidas Caregiver Conference in late October 2016.  She took some notes from the various talks.  Here are Denise’s notes from the talk on “Patient Rights and the Discharge Planning Process” presented by Paula Wolfson, the Avenidas senior center social worker.

The main resource mentioned by Ms. Wolfson was the Medicare website and its explanation of the discharge appeal process:

The remainder of Denise’s notes are copied below.


Notes from Brain Support Network volunteer Denise Dagan:

The last information session I attended at the Avenidas Caregiver Conference was titled, “Patient Rights and the Discharge Planning Process.”  It was presented by Paula Wolfson, a social worker with Avenidas.  We learned to “…effectively mediate and negotiate [hospital] discharge plans.”  Ms. Wolfson gave us so much related information I could not possibly summarize it all here.

Through several hospitalizations for my parents, myself, and my daughter, I’ve never heard of, nor been invited to, a discharge planning ‘meeting’.  Whether an actual meeting happens, all of these people are involved in the discharge process.  Any one of them can question the readiness of a patient for discharge and slow, or stop the process until all requirements are in place for a safe discharge that meets all the patient’s recovery needs.

– The physician, who recommends and writes the discharge orders

– The physical, occupational and speech therapist team, to determine if the patient is at risk for falling or not able to perform the activities of daily living independently, and make recommendations for in-home or skilled care upon discharge

– The social worker, who reviews the patient’s social supports, housing, medical follow up resources, transportation, financial and legal concerns

– The nurse case manager, to assists with skilled care discharge placements and insurance coverage

– The patient and his/her designated caregiver, who should evaluate the discharge plan to determine if it accommodates all personal care, safety, medical follow up, transportation, and financial concerns for the patients recovery.

If you feel discharge is premature or not safe you have the right to appeal.  Consult with the nurse case manager or social worker.  They can arrange for you to have a conversation with the physician to extend the discharge until your concerns are addressed. This often works well because the Medicare appeals process is a major hassle for the hospital.  If the doctor is dismissive of your concerns, let him/her know you are prepared to file an appeal with Medicare.  Upon hearing that news, he or she should postpone the discharge for a day, or two.  Start working with the discharge team immediately to resolve your concerns.

If you feel you must appeal, during the admissions process and a few days prior to discharge you receive information about how to file a Medicare appeal.  If you can’t find it, request the “Important Message from Medicare” from the hospital admissions or business office.  This is an instructional guideline on appealing your hospital discharge and will explain the appeal process.  It gives you a phone number to call Medicare and advocate for the appeal which will trigger an independent review of the discharge decision and delay in the discharge date.  Medicare will pay until the appeal is resolved.  Complete information is available at:

This website also has information about filing a complaint (grievance) about the quality of care or other services you get from a Medicare provider, and how to file an appeal if you have issue with a plan’s refusal to cover a service, supply, or prescription.