Pinellas/Pasco 727-787-8677 and Hillsborough 813-884-6100
Pinellas/Pasco 727-787-8677 and Hillsborough 813-884-6100


Let’s Talk! – With Nurse Ruth

Years ago (and I’m not talking about the Jurassic period), on the day of admission, it was protocol to collaborate with social services on discharge planning. Today, protocol is still the same; discharge plans for a patient start on the day of admission. However, because of the influence of the health insurance industry, the patients are discharged earlier. In many cases, although they are medically stabilized, they’re still not able to care for themselves. So, my friends, please note: each family needs to actively participate in the discharge plans of their loved ones.

  1. Safety First: You should realize that the home environment prior to the illness/hospitalization may no longer be sufficient or safe upon discharge. The patient may need a short-term admission to a rehab facility prior to going home. The hospital is required to make this referral and it is the individual’s choice where they go.
  2. Entitlement: Upon returning home, your family member may be entitled to home care. This requires a physician’s order for physical therapy, occupational therapy and skilled nursing. Also, included in those discharge orders should be any durable medical equipment needed in the home. Nutritional counseling is also covered under Medicare and can be ordered by your physician. This is very important for patients with diabetes or kidney disease. However, depending on medical insurance, this can vary.
  3. Plan: Upon discharge to the home, you should have the following: any new medication prescriptions, diet change information, activity restrictions, information on follow-up doctor appointments, and home health referrals, when appropriate.
  4. Knowledge: You should have received, or had explained to you, the present medical status of your family member and any ongoing treatment that may be necessary. Also, you should be given names of any specialists needed for the care of the patient.

It is important that the family be involved and included in the discharge planning of your loved one. You can also request a care plan meeting with Case Management to discuss short- and long-term goals.

Discharge planning is a collaborative effort by the health care team. It should include the patient and his/her family. Active participation by your primary care physician and nurse is important for a smooth transition home.

If you have a concern, viewpoint or comment with regard to this subject matter, Let’s Talk!

Provided by Ruth Fanovich, RN, LHRM, Owner, Care Placement Home Health Agency, Inc. and RMF Care Management, Inc.