What is the role of a hospital discharge planner?

Key points:

• A hospital discharge planner helps patients transition safely back into the community
• Discharge planners are the bridge between hospital and home for patients
• You will receive an individualised discharge plan outlining your time in hospital and future care, service and medication needs

But leaving the hospital after an illness or fall can be scary. You may be worried about getting injured again or don’t have the necessary supports in place to keep you safe at home.

This is where a hospital discharge planner can assist you to safely reenter your home. They ensure and can organise the necessary supports for you when you return home and provide information on better options to suit your new needs.

What is a hospital discharge planner?

In hospitals, discharge planning is an important step to ensure that a person leaving the hospital is safely able to reenter the community.

A hospital discharge planner works with patients to determine whether it is safe for them to leave the hospital and return home, as well as making sure future care needs are covered.

Effective discharge planning can reduce readmission to hospital, the length of a patient’s stay, improve the quality of life for an older person through relevant supports and care, and lead to better health outcomes.

For older people, hospital discharge planners can be really important as they can ensure a continuity of care for an older patient once they leave a hospital.

Discharge planners also organise supports and services you require once you leave hospital. This can include organising having an Aged Care Assessment Team/Service (ACAT/S) visit you in hospital for an aged care assessment to access Government funded home care options, short term care options or aged care.

If you only need temporary help after a hospital stay, then a hospital discharge planner may suggest organising assistance through the Transition Care Program, the Short Term Restorative Care program, or similar programs that assist you for a short time at home.

Sometimes, you may not even go straight home after a hospital stay and spend some time in a rehabilitation centre or clinic to help you recover from your injury or illness.

Hospital discharge planners can also provide guidance through the process of applying for a bed in a residential aged care facility. While they can help you through the process of how to access and apply, they cannot help you choose a nursing home.

How does the discharge process work?

Generally, your discharge planner will start the process once you enter the hospital, and this should include not only you but your family and hospital staff.

The discharge planner should talk to you about why you ended up in hospital, discuss your patient assessment, and your personal goals for your health. They will then put together a discharge care plan to follow once you are back in the community.

Your planner will also discuss medications you need to take, any equipment you may need outside of the hospital like walkers and wheelchairs, and rehabilitation options if you require it.

Your hospital discharge planner will also try to understand what life is like for you at home. For instance:

• Do you live at home alone?
• Is someone dependent on you for care?
• Are you receiving any assistance from family and friends or community care services?

Your home life can have an impact on services you may need when you return to your home, especially if you are still feeling weak after your hospital stay.

For older people, a hospital discharge planner may be the beginning step for organising important community care or home care services or the start and implementation of moving into a nursing home.

Your discharge planner will organise, on your behalf, any community supports and services you need to assist you at home, this includes organising relevant assessments for services that are Government funded.

What is included in my discharge plan?

Your discharge care plan will fully detail everything that happened from the second you entered hospital and the care you received during your stay to what you need to do after you leave and are back at home.

This can include:

• A summary of why you entered hospital
• What occurred while at hospital, including any tests you had or any surgeries or medical treatments were done
• Any allergic reactions you had to medication or anything else during your stay
• Past medications you have taken as well as what medication you were provided to take home with you when discharged
• What you need to do after you leave hospital
• Outline of the services that have been organised for you once you leave hospital, including directions on when to see your doctor for a check-up

Once you leave a hospital, you will receive a copy of the discharge plan that was made for you, which will advise you on what to do once you are back living at home.

You should give a copy to the important people in your life, including your carer or family members, as well as any service providers or your residential aged care facility.

How has a hospital discharger planner assisted you in returning home after a hospital stay? Tell us in the comments below.

Related content:

When should I consider help at home?
How short-term restorative care can get you back on track
Regaining your independence at home
Do I need transition care?