George gripped his wife Anne’s hand tightly as the ambulance rushed them to the hospital. As George looked at her lying on the stretcher, he could tell she was in immense pain.

Guilt and worry overcame him as he replayed her fall in his mind. Earlier that day, Anne left their breakfast table to get George’s cane from the living room. She accidentally caught her foot on their rug and with nothing in reach to break her fall, she collapsed on the wooden floor.

The EMTs in the ambulance suspected that Anne had broken her hip. At the hospital, doctors confirmed the injury. George and Anne were braced for the worst when the doctors said she would need surgery. However, they assured the couple that everything would go smoothly. Anne’s hip was soon surgically replaced with a titanium rod.

A while later, Anne was finally well enough to go home. The hospital staff instructed Anne and George of their orders for the rehabilitation of her hip. Anne would need physical therapy, medication, a wheelchair, check-ups and constant monitoring to continue her recovery. Afterward, George and Anne were visited by the hospital discharge planner.

“You should be very proud of your swift recovery,” said the discharge planner. “George, you should be just as proud of how diligent you were in caring for your wife. I’m afraid there is still more to do, though. Your insurance completed the coverage of your hospital stay, and since you’re well enough, it’s time for your discharge. Your doctors say you’ll need more care when you leave. Together, we are going to find the best way to do that.”

Senior citizen families and patients like George and Anne persevere through illness or injury only to find themselves facing the unknown after discharge. It is enough of a struggle to make it through emergencies, hospital procedures and anxiety hanging on hopes for good recovery. But after leaving the hospital, senior patients like Anne are just beginning their journey towards restored health.

The number one challenge for senior patients is to avoid being reinjured or developing a health complication that will require readmittance to the hospital. A study by the Journal of the American College of Surgeons noted that “readmission risk increases for elderly patients with geriatric-specific characteristics.” These include being a fall risk, using a mobility aid and needing care at home.

What should you do when you are facing the unknown after discharge? This article’s helpful information will provide some tips to assist you.

Who is Involved in Hospital Discharge?

  • Patient – The patient – in this case, Anne – succumbs to illness or injury and receives treatment from the hospital. He or she has the right to discharge into any short-term or long-term post-treatment situation, so long as they are mentally capable. The patient can also discharge themselves against medical advice and refuse their care needs. Most patients want to come to the safest and healthiest solution possible.
  • Family Member / Caregiver – George is the family member involved in this story. His role is vital to Anne’s discharge planning because he knows Anne’s needs and preferences intimately. He is also the one who will most likely manage Anne’s care after leaving the hospital.
  • Doctor / Physician – The doctor or health care physician provides a significant amount of input into the patient’s discharge process. They will make the best recommendations for continuing the patient’s physical and mental well-being. They also have the authority to finalize discharge plans, prescribe medication and order further treatment, if necessary. Know that the doctor or physician in the hospital is usually not the family physician who patients see regularly. Therefore, relaying accurate information between the two is critical.
  • Nurse – While a patient is in the hospital, multiple nurses take care of them at all times of the day. They observe the patient’s mental status, stamina, ability and willingness to follow directions. Their judgments of these factors are communicated to the discharge planner.
  • Discharge Planner – The hospital discharge planner is usually a nurse or social worker. It is their job to coordinate what happens during and after hospitalization or care discharge. They also advocate for both the hospital and the patient. They juggle factors like cost-effective insurance coverage, doctors’ orders, nursing home options and patient preferences to plan the best follow-up care after hospital treatment.

Before Discharge

Families must discuss discharge planning together, preferably before a loved one is ever admitted to the hospital. With senior citizens, the likelihood of illness or injury is high, but the likelihood of efficient care coordination may not be. Spouses, siblings, children or caregivers have necessary input when it comes to the care of elderly loved ones. It is essential that all people involved are on the same page when planning what to do if a senior loved one must go to the hospital.

Understand insurance coverage thoroughly. The patient, family members and caregivers should be informed enough to plan for the length and depth of hospital treatment and coverage of outpatient care. The patient’s needs and preferences, such as who they are comfortable receiving care from, where they are safe and how they will continue to function must be communicated.

In general, find the source of funding and plan to make them as comfortable as possible when their life changes after leaving the hospital. The discharge planner should be included in all these conversations. You can also reach out to an Amada Senior Care advisor with any caregiving questions you might have about funding—from Long-Term Care and Home Health Care insurance policies to Veterans Administration benefits to special options. Click here to find an Amada Senior Care location near you or call us toll-free at 877-44-AMADA.

Helping the Discharge Planner Help You

As mentioned, the discharge planner is responsible for coordinating all aspects of the patient’s discharge from the hospital. He or she wears several hats. They have to balance what is cost-effective for the hospital with the patient’s wishes and wellbeing. They also establish relationships with community agencies outside the hospital, such as rehabilitation centers, nursing facilities, hospices and home health companies.

One issue for discharge planners is the dilemma patients face if their insurance no longer covers hospital treatment, but they need more care. The discharge planner does their best to secure a fluid transition from hospital to home so that recovering patients do not have to be readmitted to the hospital. This job is impossible without your clear, assertive communication.

Discharge planners actually want you to ask questions, be honest and request anything you need. The more a discharge planner knows about all aspects involved in your in-home recovery, the better. Talk to your discharge planner about the environment your elderly patient will go to, who will be present for their recovery, what tasks he or she will need help with and how you feel about absolutely everything.

The Family Caregiver Alliance offers a list of questions to ask at the end of this article on discharge planning. It is the discharge planner’s job to consider your needs and preferences to secure the services necessary for a full recovery.

After Discharge

George’s first thought about Anne’s recovery after discharge was that he would be her only source of help. But since George already suffered serious physical injuries in the past, he was unable to give complete care to Anne at home. Humbly, George communicated this to the discharge planner. Anne supported him, saying she would not want George to reinjure himself helping her bathe, move around the house or carry their shopping. Before her fall, she had been doing most of the heavy lifting anyway.

The discharge planner appreciated their honesty and informed them of other options. George and Anne worried whether they could pay for so many services. But they learned Anne held a long-term care insurance policy, and she could be covered for either in-home care or a rehabilitation center stay.

Feeling quite relieved, Anne looked at George and saw loyal support in his eyes. “I want to be close to my husband, so I’d like to stay at home,” she told the discharge planner.

After a call to their nearest senior care agency, the discharge planner coordinated round-the-clock caregiver and physical therapist visits to George and Anne’s home. The caregivers and nurses scheduled to see Anne would work on completing the recovery of her hip for as long as necessary.

Since George and Anne were transparent about their needs and preferences, their discharge planner found them the perfect solution. Anne continued to grow stronger at home, thanks to her caregivers and nurses. George’s worry decreased every day he saw Anne’s health improve. Their diligence and communication gave them more control over the unknown after discharge. Thankfully, this helped Anne make a speedy recovery.


“Facing the Unknown After a Hospital Discharge,” written by Michelle Mendoza and updated by Michelle Flores, Amada contributors.