Discharge planning is the process of transitioning a patient from one level of care to the next — from hospital to home, rehabilitation facility, or longer-term care setting. Federal law (42 CFR 482.43) requires hospitals to have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and caregivers as active partners.
31 steps across 7 sections
1. Medications
- Obtain a complete, written list of all medications (name, dose, frequency, purpose)
- Compare pre-admission medication list with new discharge list — note anything added, removed, or changed in dose
- Complete medication reconciliation with a pharmacist or nurse before leaving
- Understand potential side effects and drug interactions
- Confirm you have prescriptions filled or know which pharmacy will fill them
- Ask about medications you should stop taking or avoid (including OTC drugs and supplements)
2. Discharge Instructions
- Receive written instructions covering your diagnosis, treatment received, and ongoing care needs
- Understand activity restrictions (lifting, driving, bathing, stairs, exercise)
- Know wound care procedures (cleaning, dressing changes, signs of infection)
- Understand dietary restrictions or requirements
- Know specific red-flag symptoms that require emergency care: fever/chills, chest pain, shortness of breath, sudden confusion, new/spreading swelling, pain escalating despite medication, drainage wi...
3. Follow-Up Appointments
- Schedule all follow-up visits before leaving (primary care, surgeon, specialists)
- Know dates and locations of scheduled lab work or imaging
- Have therapy start dates (physical, occupational, speech) if applicable
- Get names and phone numbers for all providers you will need to see
- Know who to call with questions after discharge (24-hour nurse line, doctor's office)
4. Equipment and Home Needs
- Arrange for durable medical equipment (wheelchair, walker, hospital bed, oxygen, etc.)
- Confirm insurance coverage for equipment and home health services
- Assess home safety needs (grab bars, ramps, shower chair)
- Arrange home health aide or nursing visits if needed
- Set up medical alert system if living alone
5. Medicare Patients (Original Medicare)
- Request a QIO review. Contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) listed on your Important Message from Medicare notice.
- File by the deadline. You must request the appeal no later than the planned discharge date. If you file on time, you can stay in the hospital during the review at no additional cost (other than nor...
- Hospital responds. By noon the day after the QIO notifies the hospital, the hospital must provide you a "Detailed Notice of Discharge" explaining why they believe discharge is appropriate.
- QIO decides. The QIO will notify you of its decision within 1 day after receiving all necessary information.
- If the QIO agrees with the hospital, you become financially responsible for your care starting at noon the day after you receive the QIO's decision.
6. Medicare Advantage Patients
- Follow the same QIO process, but also check your plan's specific appeal procedures
- Your plan must continue coverage during the appeal if filed on time
7. Non-Medicare Patients
- Review your insurance policy's appeal and grievance procedures
- Contact your state insurance department if you believe you're being discharged unsafely
- File a complaint with the state health department or The Joint Commission (if the hospital is accredited)
Common Mistakes
- Not requesting an itemized discharge summary
- Skipping follow-up appointments
- Not doing medication reconciliation
- Leaving without understanding warning signs
- Not asking about costs
Pro Tips
- Bring a notebook and a second person
- Ask for the "teach-back" method
- Request discharge during daytime hours
- Get the direct phone number
- Take photos of wound sites
Sources
- Medicare Discharge Planning Checklist
- Discharge Planning - StatPearls (NIH)
- CMS Discharge Planning Worksheet
- Discharge Planning - Center for Medicare Advocacy
- 42 CFR 482.43 - Condition of Participation: Discharge Planning
- Medicare Hospital Discharge Rules (NCOA)
- Leaving the Hospital - Your Discharge Plan (MedlinePlus)
- Hospital Discharge Planning and Patient Rights for Seniors
- Medicare Fast Appeals
- Important Message from Medicare (CMS Form R-193)
- How Medicare Beneficiaries Can Fight a Hospital Discharge
- AHRQ IDEAL Discharge Planning Checklist
- Post-Discharge Checklist (Family Caregiver Alliance)
- Discharge Instructions Explained (CARE Homecare)
- Hospital Discharge Checklist (Seniors at Home)