Preparing for Hospital Discharge

How to set up follow-up care

Hospital discharge planning begins earlier than one may think. The medical care team will assess your loved one’s medical needs and seek help from rehabilitation experts to determine how much rehabilitation they will need after the hospital. Some people need skilled nursing care while others may benefit from either inpatient or outpatient rehabilitation. Your loved one will likely require many outpatient follow-up appointments after discharge.

Discharge planning begins when your loved one is ready to be transferred from the intensive care unit (ICU) to the inpatient floor. Each day, the medical care team will think about what treatment, rehabilitation, and resources the patient will need after leaving the hospital. Your loved one will likely have a different care team in the ICU versus on inpatient floors.

Knowing this information could empower your loved one and family members to effectively communicate with the medical care team and facilitate streamlining of discharge planning.

Possible discharge destinations: 

• • Skilled nursing facility or long-term acute care facility for the continuation of medical care. Such care may include intravenous medications, ventilator or tracheostomy management, and feeding tube management. These facilities are suitable for people who cannot remain awake long enough to meaningfully participate in rehabilitation.
  • Acute inpatient rehabilitation at a specialized facility prior to going home from the hospital. Typically, there is a minimum requirement for three hours a day of rehabilitation and in more than one area of rehabilitation.
  • Visiting nurse or home health aide who visits daily or a few times per week. This may be an intermediate step before transitioning to outpatient rehabilitation.

In the United States, insurance status and coverage in terms of the number of benefit days or visits often play a role in access to these discharge resources. Rehabilitation needs may be treated by physical therapists, occupational therapists, or speech-language pathologists. Collectively, coverage for treatments by these professionals is often capped at approximately 30 or 60 (sometimes more) visits or sessions. Treatment recommendations and priorities need to be coordinated carefully. If your loved one uses up too many rehabilitation visits for a physical concern, they may have to pay out of pocket for other services, such as speech or occupational therapy. 

Timing of in-hospital assessments and availability of beds at inpatient facilities may be critical to qualification and access as well. For example, if your loved one meets the criteria for inpatient rehabilitation on a Friday, but no bed is available, reassessment on Monday may actually show that they have improved “too much” and no longer qualify for this level of care. The care team should be thinking about these issues on a daily basis – and potentially even weeks ahead.

Discharge planning and follow-up care should be personalized for the patient. However, people commonly need follow-up for: 

• • Physical symptoms (weakness, pain, deconditioning)
  • Neurological symptoms (seizures, movement disorders)
  • Cognitive symptoms (fatigue, communication, memory, multitasking)
  • Psychological symptoms (anxiety, depression, post-traumatic stress)
  • Social or spiritual symptoms (return to work, return to hobbies, “why” or “why me”)
  • Coordination of care (medication review, rehabilitation, assessment or referral to additional specialists)

Where your loved one goes after discharge may determine when they will follow up with certain specialists. If your loved one goes straight home, they will need appointments scheduled within 1 week. Your loved one or their care team can begin to make some of these appointments before they even leave the hospital. If there is an ICU follow-up clinic or cardiac arrest clinic available to your loved one, this may be a good option to address many of the complex issues addressed here. Not many specialty clinics exist, however. The primary care doctor may or may not be familiar with recovery and rehabilitation needs after cardiac arrest. 

If your loved one goes to inpatient rehabilitation, a skilled nursing facility, or a long-term acute care facility, specialists should come to them. However, you or your loved one may need to advocate for some specialists to be involved in these settings. Insurance coverage will also determine how long (measured in days) care at these facilities is available. For example, if rehabilitation progress is not evident or consistent at an inpatient rehabilitation facility, moving services to a skilled nursing facility may be necessary until your loved one is well enough to participate in rehab again, thus saving additional “days” covered as inpatient rehab. 

Finally, transitioning from inpatient rehabilitation, a skilled nursing facility, or long-term acute care to home will require significant coordination of resources and information. Your loved one should ask that they, along with you and any other family members/personal advocates, be involved in discharge planning conversations with doctors, care managers, and rehabilitation specialists.

Thank you to our contributors

Kelly Sawyer & Jasmine Wylie