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. Leaving the hospital doesn’t mean that you’re completely well. It means that your doctor thinks that you don’t need to be in a hospital.

Your discharge plan may include going to:

  • Your own home or someone else’s home
  • A rehabilitation (rehab) facility
  • A nursing home

Your healthcare team may also recommend services, such as a visiting nurse, equipment, or short-term placement for rehabilitation. If you need any services, your case manager (a member of your healthcare team who helps to plan and coordinate your services) will work with your insurance company and agencies to arrange for them.

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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 doctors, nurses, and social workers will work with your case manager to figure out what you may need when you leave the hospital.

 
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When does discharge planning happen?

Discharge planning may begin before you’re 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 will discuss this with you during your hospital stay and change your plan as needed.

If you’re admitted to the hospital through the Urgent Care Center (UCC), your healthcare team will begin your discharge planning at that time. They will keep you updated on what you can expect when you’re discharged.

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

Insurance benefits are different for everyone. The kind of services you can have after discharge will depend on your insurance and your condition. People are often surprised to learn that their insurance may not pay for many services or items they need after discharge.

If you know that you’re going to be admitted to the hospital, contact your insurance provider. Ask about your home care and long-term care benefits. However, even if your policy includes home care or long-term care benefits, your insurance provider may feel that it’s not necessary for you at the time. If so, they may not pay for it. You can talk with your case manager about calling your insurance company to discuss your coverage. If you need or want services that your insurance doesn’t cover, you have the option of paying for them on your own. Talk with your social worker for information about financial resources that may be available to you, if you’re eligible.

Your insurance provider 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.
  • What services they feel you need.

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

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What are some of my care options after I’m discharged 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 provider, but your insurance provider makes the final decision 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 agency that your insurance provider prefers. The home care agency will then work with your insurance provider 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 for some services yourself.
  • Acute rehabilitation facilities provide intense physical therapy (PT). 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.
  • Skilled nursing homes provide specific services, such as wound care, giving medications through an IV, or PT. To be admitted into one of these facilities, your doctor must feel that your condition can improve. Services are often provided in a skilled nursing facility.
  • Hospice care is care for people near the end of their life. Hospice care is given by a team, including a doctor, nurse, home health aide, social worker, and spiritual counselor. This team focuses on the way you feel physically, emotionally, and spiritually.
    • Inpatient hospice care provides palliative and end of life care in an inpatient setting. 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 end of life care for you in your home. Local visiting nurse associations and hospice agencies provide care and support. Your insurance may pay for these services.
 
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Will my insurance cover transportation from the hospital after I’m discharged?

If you need transportation from the hospital, you will have to pay for this on your own since it isn’t usually covered by insurance. It’s best to have family or friends drive you.

If you’re discharged to another facility, your case manager will check to see if your insurance covers transportation. If it doesn’t and your family or friends can’t 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. Our outpatient pharmacy at Memorial Hospital is located at:

425 East 67th Street
Haupt Pavilion, Room A105
New York, NY 10065
646-888-0730

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, the agency’s name and phone number will be listed on your written discharge instructions. Your discharge instructions will also list when the services will start. If you have any questions about these services, ask your case manager.

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

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, and any concerns you may have about leaving the hospital.

If you have any questions after you’re discharged, contact your doctor’s office. You can also contact Case Management directly by calling 212-639-6860.

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