Planning for Your Discharge

This information explains the process of being discharged from your hospital stay at Memorial Sloan Kettering (MSK).

What is discharge planning?

Discharge planning is the process by which your healthcare team gets you ready to leave the hospital. Your team looks at what care you will need after you leave. Your plan may include going to:

  • Your own home or someone else’s home with or without services
  • A rehabilitation facility
  • A nursing home

Leaving the hospital does not mean that you are completely well. It means that your doctor thinks that you do not need to be in a hospital.

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When does discharge planning happen?

Discharge planning may begin before you are admitted to the hospital. If your admission is planned, your doctors and nurses may be able to tell you about how long you will stay in the hospital. They, along with your case manager, can also tell you what care needs you may have when you leave. They will discuss your needs during your hospital stay and change your plan as needed.

If you are admitted through the Urgent Care Center, your healthcare team will begin the discharge planning at that time. They will keep you updated on what you might expect when you are discharged.

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Who is responsible for my discharge?

Only a doctor can discharge you from the hospital. However, many people work on the details of your discharge plan. Your doctor, primary nurse, and case manager will work with you to understand what you may need when you leave the hospital. They may recommend services, such as a visiting nurse, equipment, or short-term placement for rehabilitation. If you need any services, your case manager will work with your insurance company and any agencies to arrange for them.

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How will I know what services my insurance will cover after I am discharged?

Insurance benefits vary. The kind of services you can have after discharge will depend on your insurance and your condition. Patients and family members are often surprised to learn that their insurance may not pay for many services or items they need after discharge. Even if your policy includes home care or long-term care benefits, your insurance carrier may feel that it is not medically necessary for you at the time. If so, they may not pay for it. If you need or want services that your insurance does not cover, you have the option of paying for them on your own.

If you know that you are going to be admitted to the hospital, contact your insurance carrier. Ask about your home care and long-term care benefits. Your insurance carrier makes the final decision about what they will pay for. Their decision is based on:

  • Information provided by your medical team
  • Your insurance plan’s covered benefits
  • Their assessment of your needs and condition

Your case manager will work with you to see what your insurance will cover. He or she will review your options with you and your caregivers.

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What are some of the options for care after discharge from the hospital?

Some people only need the help of family and friends when they leave the hospital. If you need more care, there are several options listed below. Your case manager will work with your insurance carrier on your behalf, but your insurance carrier has the final say about what services they will and will not cover.

  • Visiting nurse services provide care for you at home, such as caring for a wound or giving you medication through an intravenous catheter (IV). Your case manager will arrange for these services with a home care provider that your insurance carrier prefers. The home care agency will then work with your insurance carrier to decide the number of visits you will need. Your visit schedule will be changed as your care needs change. You may have to pay out-of-pocket for some services.
  • Acute rehabilitation facilities provide intense physical therapy. You must be able to spend about 3 to 5 hours a day in therapy sessions. This is usually for a short term stay of 1 to 2 weeks.
  • Subacute rehabilitation facilities and skilled nursing homes provide specific services, such as wound care, giving medications through an IV, or physical therapy. Your doctor must believe that your condition can improve. Services are often provided in a skilled nursing facility.
  • Hospice care provides inpatient palliative and end of life care. It can also provide short-term care (such as wound care or IV antibiotics) if you need to stay in an inpatient setting.
  • Home hospice care provides care for patients who wish to stay at home. Local visiting nurse associations and hospice agencies provide care and support. Your insurance may pay for these services.

If you need transportation from the hospital, you will have to pay for this on your own, since it is not usually covered by insurance. It is best to have family or friends drive you. If you are discharged to another facility, your case manager will check to see if your insurance covers transportation. If it does not and your family or friends cannot take you, your case manager can suggest a car or ambulance service. You will have to pay for this.

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What happens on the day of my discharge?

On the day of your discharge, your doctor will write your discharge order and prescriptions. You may fill your prescriptions in our outpatient pharmacy or at your usual pharmacy.

You will receive written discharge instructions, including information about your medications. Before you leave, your nurse will review these instructions with you and teach you how to do any self-care that you will need. Make sure that you understand how much medication you need to take, how and when you should take it, and what the possible side effects of your medication are. Also, make sure that you know when you should call your doctor. If you have any questions or concerns, ask your nurse and write down the answers.

If home care services have been arranged for you, their name and phone number will be listed on your written discharge instructions. Your discharge instructions will also list when the services will start. Please ask your case manager if you have any questions on these services.

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Who can we contact if my caregivers and I have questions?

Talking about discharge sometimes takes place at times of stress. If you have any questions or concerns about leaving the hospital, talk with your doctor, nurse, or case manager. Social workers are also available to help you and your caregivers cope with your illness and treatment, as well as deal with your concerns about leaving the hospital.

If questions come up while you’re at home, contact your doctor’s office. If you prefer to contact Case Management directly, call 212-639-6860. We are here to help you!

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