Discharge planning is the process of safely transitioning a patient out of the hospital to the next appropriate level of care. A hospital social worker or case manager assesses medical, functional, and social needs, then coordinates the right setting — home with services, a rehabilitation facility, skilled nursing, or assisted living. It begins at admission and should involve the patient and family throughout.

Discharge planning should begin within 24 hours of admission. In practice, many families do not hear from a discharge planner until day two or three — sometimes not until the evening before discharge. If no one has contacted you by day two of a hospital stay, ask the nursing staff to connect you with the discharge planner or social worker immediately. Do not wait for them to come to you.

The discharge planner is typically a hospital-employed social worker or case manager. They work for the hospital, not for your family. They are under pressure to discharge patients as soon as they are medically stable. They may not know every community resource available, and their recommendations often reflect what is convenient or contracted rather than what is best for your specific loved one.

Options include: going home with home health care or outpatient therapy; a short-term inpatient rehabilitation facility (IRF) for intensive therapy; a skilled nursing facility (SNF) for lower-intensity rehab and nursing care; assisted living if long-term support is needed but not skilled nursing; memory care for dementia-related conditions; or long-term acute care (LTAC) for medically complex patients. The right choice depends on diagnosis, functional status, and available support.

No — but the hospital can stop billing insurance once a patient is deemed medically stable, shifting costs to the patient. Medicare patients have the right to appeal a discharge decision. File an appeal with the BFCC-QIO (Livanta in Texas) before midnight on the day you receive the discharge notice. The hospital must keep your loved one during the review period at no additional cost.

Medicare patients must receive written notice — the Important Message from Medicare — at least one day before the planned discharge date. You have until midnight that day to appeal. For non-Medicare patients, requirements vary by insurance. Texas law requires hospitals to give reasonable notice and make appropriate referrals. Regardless of insurance, always ask for written discharge instructions and a full discharge summary.

The discharge summary should include: the primary diagnosis and any secondary diagnoses, all treatments and procedures performed, current medications with dosages, follow-up appointment instructions, activity restrictions, warning signs to watch for, and contact information for the care team. Request this document in writing before leaving. Bring it to every subsequent care provider — gaps in this information are a leading cause of post-discharge complications.

Medically stable means the acute episode has been controlled and hospital-level care is no longer required. It does not mean fully recovered or safe to live independently. A patient can be medically stable and still need 24-hour supervision, wound care, IV medications, or intensive physical therapy. Always ask what functional abilities have been assessed and what ongoing care needs remain before accepting a discharge plan.

Hospitals cannot ethically discharge a patient to an unsafe situation. If your loved one cannot return home safely and you have not yet identified an appropriate facility, tell the discharge planner directly. Request a care conference. A senior care placement agent can often identify appropriate assisted living or skilled nursing options within 24 to 48 hours. Do not accept discharge to an unsafe situation without exhausting all options.

A placement agent like Erika Crossley can rapidly assess your loved one’s needs, identify appropriate Texas facilities with available beds, advocate for the right level of care, and guide the family through a high-pressure decision in hours rather than days. This service is free to families — agents are compensated by the facilities. In a discharge crisis, having an experienced advocate saves time and prevents dangerous placements.

Ask: What level of care does my loved one need now and in 30 days? What specifically triggered this discharge? What are ALL the options, not just the one you are recommending? Does my loved one qualify for inpatient rehabilitation? What does insurance cover and for how long? Can we delay discharge 24 hours to properly evaluate options? What happens if the placement does not work out?

Accepting the first recommendation without asking questions. Hospital discharge planners are not obligated to find the best option — only an adequate one. Families who do not know their rights, do not ask for alternatives, or who feel pressured to make an immediate decision often end up in facilities that are not a good fit. Take the time to ask questions, request alternatives, and involve a placement specialist if possible.