Full Definition

Discharge planning is the formal process a hospital undertakes to prepare a patient for safe discharge from the hospital and transition to the appropriate next care setting. For older adults, post-acute discharge decisions — whether to return home, go to a skilled nursing facility, inpatient rehabilitation, or another setting — are among the most consequential choices families face, often made under significant time pressure.

In Medicare-covered hospital stays, patients have specific rights related to discharge planning: the right to be informed that discharge planning services are available; the right to receive a discharge plan; the right to be involved in discharge planning; and the right to receive a list of Medicare-certified post-acute care providers in the area.

Critically, hospital discharge planners typically present a limited list of facilities — often those the hospital has existing referral relationships with — not necessarily the highest-quality options in the area. Patients and families have the right to choose any willing and able provider, regardless of the hospital’s suggested list.

A Notice of Medicare Non-Coverage (NOMNC) is issued when Medicare stops covering hospital care. Patients have the right to appeal this decision through the Beneficiary and Family Centered Care QIO (BFCC-QIO) before discharge — and can continue receiving Medicare-covered hospital care while the appeal is pending. Understanding this right can prevent premature, unsafe discharges.