Your Discharge Planning Checklist


Your Discharge Planning Checklist:

For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting

NAME: ___________________________________________________________________
Reason for admission: __________________________________________________

During your stay, your doctor and the staff will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. Below is a checklist of important things you and your caregiver should know to prepare for discharge.

Instructions:

Use this checklist early and often during your stay.
Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on the checklist.
Check the box next to each item when you and your caregiver complete it.
Use the notes column to write down important information (like names and phone numbers).
Skip any items that don’t apply to you.

ACTION ITEMS NOTES

What’s Ahead?
Ask where you will get care after discharge. Do you have options (like home health care)? Be sure you tell the staff what you prefer.____________________________________________
If a caregiver will be helping you after discharge, write down their name and phone number.________________________________________________________________________________

Your Health
Ask the staff about your health condition and what you can do to help yourself get better._______________________________________________________________________________
Ask about problems to watch for and what to do about them. Write down a name and phone number to call if you have problems.__________________________________________________
Use “My Drug List”on page 5 to write down your prescription drugs, over-the-counter drugs, vitamins, and herbal supplements.______________________________________________
†Review the list with the staff._______________________________________________________
†Tell the staff what drugs, vitamins, or supplements
you took before you were admitted. Ask if you should still take these after you leave.
______________________________________________________________________________________
†Write down a name and phone number to call if you have questions._____________________

Recovery and Support
†Ask if you will need medical equipment (like a walker). Who will arrange for this? Write down where to call if you have questions about equipment._____________________________
†Ask if you’re ready to do the activities listed below. Circle the ones you need help with and tell the staff.
• Bathing, dressing, using the bathroom, climbing stairs______________________________
• Cooking, food shopping, house cleaning, paying bills________________________________
• Getting to doctors’ appointments, picking up prescription drugs_____________________
†Make sure you have support (like a caregiver) in place that can help you. See “Resources” on page 6 for more information._______________________________________________________
†Ask the staff to show you and your caregiver any other tasks that require special skills (like changing a bandage or giving a shot). Then, show them you can do these tasks. Write down a name and phone number to call if you need help.________________________________
†Ask to speak to a social worker if you’re concerned about how you and your family are coping with your illness. Write down information about support groups and other resources.____________________________________________________________________________
†Talk to a social worker or your health plan if you have questions about what your insurance will cover and how much you will have to pay. Ask about possible ways to get help with your costs._________________________________________________________________
Ask for written discharge instructions (that you can read and understand) and a summary of your current health status. Bring this information and your completed “My Drug List” to your follow-up appointments._______________________________________________________
Use “My Appointments” on page 5 to write down any appointments and tests you will need in the next several weeks._______________________________________________________________
†
For the Caregiver
†Do you have any questions about the items on this checklist or on the discharge instructions? Write them down and discuss them with the staff.________________________
†Can you give the patient the help he or she needs?____________________________________
†What tasks do you need help with?_____________________________________________________
Do you need any education or training?________________________________________________
Talk to the staff about getting the help you need before discharge.___________________
Write down a name and phone number to call if you have questions._____________________†
Get prescriptions and any special diet instructions early,____________________________
so you won’t have to make extra trips after discharge.

More Information for People with Medicare

If you need help choosing a home health agency or nursing home:
Talk to the staff.
Visit www.medicare.gov to compare the quality of home health agencies, nursing homes, dialysis facilities, and hospitals in your area.
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you think you’re being asked to leave a hospital or other health care setting (discharged) too soon: You may have the right to ask for a review of the discharge decision by an independent reviewer called a Quality Improvement Organization (QIO) before you leave. To get the phone number for the QIO in your state, visit www.medicare.gov/contacts, or call 1-800-MEDICARE. You can also ask the staff for this information. If you’re in a hospital, the staff should give you a notice called “Important Message from Medicare,” which contains information on your state QIO. If you don’t get this notice, ask for it.

For more information on your right to appeal, visit www.medicare.gov/appeals. To view or print the booklet “Medicare Appeals,” visit www.medicare.gov/publications.If you have Medicare and limited income and resources, you may qualify for Extra Help to pay for your Medicare prescription drug coverage. For more information about Extra Help, visit www.medicare.gov/publications to view the booklet “Your Guide to Medicare Prescription Drug Coverage.”

My Drug List Filled out on: _________________

Fill out this list with all prescription drugs, over-the-counter drugs, vitamins, and herbal supplements you take. Review this list with the staff.

Drug Name What it Does Dose How To Take It When To Take It Notes
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

My Appointments
APPOINTMENTS AND TESTS DATE PHONE NUMBER
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Resources
The agencies listed here have information on community services, (like home-delivered meals and rides to appointments). You can also get help making long-term care decisions. Ask the staff in your health care setting for more information.

Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs): Help older adults, people with disabilities, and their caregivers. To find the AAA/ADRC in
your area, visit the Eldercare Locator at www.eldercare.gov, or call 1-800-677-1116 weekdays from 9 a.m. – 8 p.m.

Ask Medicare: Provides information and support to caregivers of people with Medicare.
Visit www.medicare.gov/caregivers.

Long-Term Care (LTC) Ombudsman Program: Advocate for and promote the rights of residents in LTC facilities. Visit www.ltcombudsman.org.

Senior Medicare Patrol (SMP) Programs: Work with seniors to protect themselves from the economic and health-related consequences of Medicare and Medicaid fraud, error, and abuse. To find a local SMP program, visit www.smpresource.org.

Centers for Independent Living (CILs): Help people with disabilities live independently. For a state-by-state directory of CILs, visit www.ilru.org/html/publications/directory/index.html.

State Technology Assistance Project: Has information on medical equipment and other assistive technology. Visit www.resna.org, or call 1-703-524-6686 to get the contact information in your state.

National Long-Term Care Clearinghouse: Provides information and resources to plan for
your long-term care needs. Visit www.longtermcare.gov.

National Council on Aging: Provides information about programs that help pay for prescription drugs, utility bills, meals, health care, and more. Visit www.benefitscheckup.org.

State Health Insurance Assistance Programs (SHIPs): Offer counseling on health insurance and programs for people with limited income. Also help with claims, billing, and appeals. Visit www.medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to get your SHIP’s phone number. TTY users should call 1-877-486-2048.

State Medical Assistance (Medicaid) Office: Provides information about Medicaid. To find your local office, visit www.medicare.gov/contacts, or call 1-800-MEDICARE and say, “Medicaid.”

The information in this booklet was correct when it was printed. Changes may occur after printing. Visit www.medicare.gov, or call 1-800-MEDICARE to get the most current information.
Your Discharge Planning Checklist” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.