What is a discharge planner? In home health care there is a saying that discharge begins at admission. In any good health care arena this is the best practice today.
What this means is that patients have been proven to get better in their own homes. The high cost of medical care however, cannot cover custodial care. Patients have to assume responsibility for their own care as soon as possible or find a caregiver or loved one to help provide this care for them. Medicare and private insurance will pay for some instruction and supervision from a home health agency after discharge from the hospital to help you make this transition.
In a hospital setting, the discharge planner is usually a registered nurse or medical social worker who has been trained in assessing patients potential needs, assisting patients to learn to care for themselves, and helping them to transition home. Sometimes this includes arranging interim care with a home health agency, or making referrals to outpatient settings to bridge the gap between hospitalization and independence.
Discharge planners have a wealth of knowledge about community resources. If you or a loved one is hospitalized and will need assistance at home, having a visit from a discharge planner is an essential part of your hospital stay. Tell your nurse you'd like to see the discharge planner. They usually work the daytime shift.
S/he will provide you with information about such things as transportation home and to and from medical appointments, meal preparation and home delivery, durable medical equipment you can rent or purchase to assist in your recovery, shopping services, etc. If you need private duty nursing care this can be arranged. If you need continued intermittent nursing visits, physical or occupational therapy once you go home and meet criteria for being homebound, a referral can be made to a home health agency.
If you have been receiving care from a home health agency prior to entering the hospital, you should report this to the discharge planner as soon as possible to ensure that you will have continued care from the same agency when you are discharged.
The discharge planner's job is to assist you in making a smooth transition either to your home or a step-down level of care such as a skilled nursing facility once you leave the hospital setting. Be sure to take advantage of this service.
