A discharge planner is a master’s degree-prepared social worker (MSW) or registered nurse (RN) who coordinates a patient’s discharge from an acute-care hospital or medical center to his home or a longer-term facility like a nursing home or rehabilitation center. Discharge planners’ responsibilities begin with a patient’s admission and continue throughout the patient’s inpatient stay, despite their title. A discharge planner usually works in a hospital’s utilization review office, which is in charge of proving to insurance companies that a patient’s continued inpatient care is necessary. Since the applicable law was passed in 1986, all hospitals that participate in the Medicare program — essentially all American hospitals — have been required to plan discharges. Discharge planning is especially important because cost-cutting measures in Western hospitals have resulted in many patients being discharged while still requiring assistance with personal or medical care.
A discharge planner starts working on a patient’s admission noting the patient’s age, diagnosis, condition, type of insurance (or lack thereof), usual degree of independence, living arrangements, and social support system, as indicated. All of this information aids in determining the general direction of the patient’s discharge plan as it develops. Regardless of how early the plan is established, a discharge planner can complete a lot of preparation work in advance of the patient’s eventual hospital release. An elderly, widowed patient, for example, who will undergo surgical repair of a hip fracture, will be discharged to an extended care facility, or nursing home, for further recovery and physical therapy rehabilitation. If this same patient were to be discharged after treatment for pneumonia, she would most likely be sent home with home health care, home oxygen therapy, and any durable medical equipment that her needs indicated.
When a discharge planner determines that a patient can safely return home, she evaluates what services the patient may require as well as what services the patient’s insurance will cover. If home oxygen is required, home health care may be indicated in the form of nursing visits, certified nursing assistant visits, physical therapy instruction, or respiratory therapy. In advance of the patient’s return home, any necessary durable medical equipment (DME) such as hospital beds, hospital bed tables, wheelchairs, bedside commodes, or walkers will be rented and delivered. If necessary, an ambulance, wheelchair ambulance, or cab will be dispatched. The discharge planner may also arrange for Meals On Wheels® or any other public nutrition program that the patient may be eligible for.
Finally, the discharge planner will schedule a follow-up visit with the patient’s doctor or doctors. A list of discharge medications will be provided, as well as drug information brochures. In addition, the patient will be given instructions to follow up on after she returns home, as well as a contact name and number in case she has any further questions.