Hospital Discharge Planning for Seniors

When it comes time for your loved one to leave the hospital, many considerations are necessary. This stage in the healing process can be just as important as the in-hospital care, and is susceptible to many pitfalls due to lack of oversight. Hospital discharge planning is the structured and adaptive approach to this transitory stage in the patient’s treatment. It is a team based approach, which can include a patient’s doctor, caregiver, family members, physical therapists, social workers and much many others. It is adaptive in the sense that every patient’s particular necessities such as rehabilitative care, medication, referrals, palliative care and transportation are taken into consideration. The key to successful hospital discharge planning is to give due consideration to all of its aspects, double check everything with specialists, and above all listen to the patient.

The Importance of Adequate Discharge Planning

For younger patients, the process of moving from the hospital is usually relatively easy: a return home and a few follow-up visits often suffice. For seniors, who may not bounce back as quickly and who often have more fragile health, discharge planning has far-reaching effects. The incorrect next step, or the failure to assess all aspects of care, can have life-changing health and wellness impacts.

The goal of hospital discharge planning is to create a smooth transition from the hospital while maintaining the best possible health outcomes. Not all seniors are able to return home after a hospitalization; many require continuing care in a nursing home, rehab facility, relative's home or a hospice facility.

Considerations for Patients and Caregivers

Many patients don't know what to expect after a hospital stay; for many seniors, the complications and considerations come as a surprise. Depending on the severity of the injury, illness, or procedure, basic tasks may become difficult or impossible. Bathing, cooking, and even getting from the sofa to the bathroom present unexpected challenges. For seniors who had existing mobility issues before the hospitalization incident, these problems may be even greater.

Some hospital stays require equipment for recovery, so caregivers and patients must select a next-stage environment that is accessible. Heavily carpeted rooms, steep stairs or narrow passageways can be impossible to navigate using a wheelchair or a knee walker.

Then, there are medical considerations. Who will change bandages and administer medications? Who will keep an eye on symptoms and call a doctor if the patient's condition worsens?

For seniors who live alone, hospital discharge planning must include personal assistance. Without another person around to help with care and provide company, the patient must consider options such as in-home healthcare or a stint at a rehabilitation facility. The same is true for seniors with far-away family who cannot help with day-to-day care.

Important aspects to look out for in the hospital discharge planning process which may include:

  • A medical evaluation that will comprehensively layout the patient’s condition, both physical and psychological, a short and long term outlook, and any further treatments which the doctor may consider medically necessary.
  • An overview of what the patient’s insurance plan will cover, including financial assistance for the caregiver, the cost in-home medical equipment and the fees incurred from healthcare facilities or medical specialists.
  • A transfer plan to the patient’s home or facility should include an explanation of the patient’s mobility limitations and how those will be overcome. Discharge planning often involves the selection of a health care facility on the spot. It is crucial for you as the caregiver to research these facilities before discharge planning begins to determine the quality of the facilities available, and whether or not they are covered under the patient’s insurance.
  • A determination of the caregiver's responsibilities is absolutely essential and will inform you if any special training or certification is needed. Carefully compare these duties to your own responsibilities to determine if you are up to the task or require assistance as a caregiver.
  • Referrals to adequate home-care agencies, facilities, specialists, support organizations or medical equipment are an essential part of hospital discharge planning. It is at this point that you should be the most vocal about your loved one’s needs to be sure they are covered under their insurance plan.
  • A detailed schedule of follow-up appointments, medication, prescription frequencies and progress expectations is a must. As a caregiver, adherence to the treatment plan is one of your chief priorities. Remember to acquire written materials in a language appropriate to the patient.
  • A reconciliation between the medications to be taken at home and those used during in-hospital treatment should be addressed to avoid possible side-effects or heavy withdrawal.
  • A diet plan and exercise regimen should be discussed with the doctor. Take notes so that you remember these details when meeting with physical therapists or nutritionists.

Options for Next-Stage Care

For many senior citizens, a hospitalization necessitates continuing care after discharge. Complex bandage changes, delicate medical procedures, and assistance with tasks such as showering and going to the bathroom may be beyond the ability and comfort level of family and friends. A variety of options exist for seniors in Ontario.

Serious health issues often require round-the-clock care by trained healthcare staff. For seniors with these needs, skilled nursing facilities are an ideal solution. With nurses, aides, and physical therapists on hand to provide medical care at any hour, the patient can heal in a safe, monitored environment.

Assisted living facilities can also provide continuing care for seniors. Staff members offer help with basic tasks that can be difficult after a surgery or procedure, such as cooking and showering. These facilities may or may not offer medical care, but they are often a convenient solution for patients who need a more gradual transition to living at home.

For seniors who are ready to go home, but still require medical care, in-home services can be a cost-effective option. Home health workers provide medical services to the patient in the home, such as dressing changes, administering medications, and physical therapy. Patients may also need part-time or full-time home care aides to help with cooking, cleaning, bathing, and mobility.

Insurance Issues

Insurance coverage plays a key role in hospital discharge planning. Coverage for post-discharge care can vary dramatically by plan and insurer. Many plans cover at-home care for a short period after a hospitalization — a time frame that may not come close to covering the full recovery process. Proper planning ensures that patients are not surprised by the high out-of-pocket costs.

Caregiver's Role in the Discharge Process

As a caregiver or responsible family member, your role begins as soon as the patient is admitted to the hospital. As it is stated above, many of the decisions that dictate your loved one’s options after discharge are made during at the time of hospital discharge planning. It is important to familiarize yourself with the patient’s condition, their insurance plan and the many health care options as early as possible. The role of caregiver is very important but also difficult.

  • You will be assuming a significant amount of responsibility, therefore your own living situation and needs have to be carefully considered to determine just how much you could realistically sacrifice physically, emotionally and financially.
  • You may be required to receive special training such as the treatment of wounds, the application of topical treatment or dressings, the administering of feeding tubes or catheters, or the appropriate way to handle a physically fragile patient.
  • You must often be a source of patience for your loved one, who may be in a hurry to get home after a long hospital stay, or having problems adjusting to new disabilities.
  • Patients with memory loss or cognitive problems as a result of Alzheimer’s disease, stroke or old age require a lot more attention and help with medical bureaucracy and paperwork.
  • Many patients with serious illnesses, disabilities and those who are vision or hearing impaired may require assistance with eating, dressing, bathing, grooming and toilet use.
  • Help with household activities is essential for some patients. This can include cleaning, laundry, cooking and grocery shopping.
  • Medication management is a big part of the caregiver's role that requires focus and mindfulness. As a caregiver you may have to administer injections, maintain prescriptions or handle appointment scheduling.
  • The caregiver is the patient’s representative and often the person with the most personal and historical information on the patient.

What if the Patient Does Not Feel Ready to Leave?

Discharge from the hospital often involves a great deal of fear for senior citizens, particularly those who do not feel comfortable caring for themselves. This fear causes additional stress, which can negatively impact healing and rehabilitation.

Excellent hospital discharge planning can help alleviate these fears. Caregivers and discharge planners must take the patient's concerns seriously and find feasible solutions. If the patient's insurance and finances allow, an assisted living facility can provide a gentler transition and help build confidence. Other solutions include a live-in aide or a move to a relative's home.

If the caregiver and patient feel that the discharge date is premature, they should work with the discharge staff to choose a different date. If that does not work, an appeal should be made to the insurance company for an extension.

Recovery Tips After a Hospitalization

Depending on the injury, hospital discharge planning may include physical therapy or rehabilitation. Caregivers and patients can speed the recovery process with doctor-approved exercise and rehab plans. For elderly patients, it is crucial to check with the primary physician before starting physical activity; doing too much, too soon can have negative health effects.

Physical activity — within the patient's abilities — can help keep muscles and joints functioning correctly. Caregivers and health workers can help the patient walk or complete simple strength-training exercises. Other options include exercise peddlers, exercise bands, hand putty, and wrist exercisers. The CDC recommends that older adults at a moderate intensity or lower. For some people, this might mean a brisk walk; for others, simply standing up might require moderate effort.

Exercise is possible for elderly patients who are wheelchair-bound after a hospitalization. Exercise bands are one solution; by repeatedly stretching and releasing the bands, patients can build strength. Caregivers can also ask the hospital about sitting workouts, which use torso and arm motions to get blood flowing and release muscle tension. Even small motions can help prevent muscle atrophy after long periods of sitting or lying down.

Many discharge plans include physical therapy. Patients work closely with licensed therapists to regain strength and range of motion. This is particularly true after a hospitalization due to a fracture or a fall, which often impact mobility. Therapy may be conducted at home or in a rehab facility. For the safety of the patient, caregivers should pay close attention to the recommendations of the doctor and physical therapist.


For senior citizens, comprehensive hospital discharge planning is an essential process. Done correctly, it can minimize the chance of readmission to the hospital and ensure the best possible health outcomes for the patient.


Mavencare offers high quality and affordable discharge planning and in-home care services. Give us a call at 1-800-856-2836 to discuss how your family and loved one may benefit from discharge planning and in-home care. You can also have a care coordinator contact you for a free home care assessment.