Hospitals may use titles such as discharge planner, case manager, nurse case manager, or medical social worker. Responsibilities vary by facility, but these professionals help connect the treatment plan with the next setting.
AHRQ recommends involving patients and families in discharge planning, describing the real home situation, reviewing medications and warning signs, explaining results, and arranging follow-up. [1]
What they may help with
Discharge destination
Ordered services
Equipment and supplies
Follow-up
Transportation needs
Insurance or benefit questions
Community referrals
Family education
Social or financial barriers
Medicare includes medical social services among covered home-health benefits for eligible patients. [2] A hospital social worker's role is not identical to a home-health social worker's role.
What families should share
Describe the actual home, available caregivers, transportation, finances, language, privacy permissions, and tasks no one can perform. Do not promise unavailable coverage.
What families still need to confirm
A referral is not the same as an accepted service. Record the organization, contact, start date, cost, eligibility, and what happens if no one calls.
Use Questions to Ask the Discharge Planner and Who Does What in Senior Care?.
Frequently asked questions
Can a discharge planner force a family member to provide care?
Families should state actual capacity and ask how the plan addresses unmet needs.
Do they choose the caregiver?
Processes vary. Families should still evaluate providers and understand any referral relationship.
Who handles clinical questions after discharge?
Use the contact named in the written discharge plan.