Free download
Hospital Discharge Planning
Your plan to come home, written down before the emergency.
Why a hospital stay can change everything
Hospitals move quickly. When an older patient cannot go home the same day, the usual next step is a short “rehab” stay in a skilled nursing facility. That stay can turn into a permanent move. It can also cost you Medicare coverage you thought you had, and it often comes with admission paperwork that no one should sign in a hurry. Families who are tired and frightened tend to say yes.
What the Home-First Discharge Card does
The card states your goal in writing: to return home, or to the least institutional setting that can meet your medical needs. It tells the discharge planner what to put in the chart before a nursing facility is proposed. It also gives your agent the right questions to ask, such as whether you are admitted as an inpatient or kept under observation, and whether the hospital has given you the Medicare notice about observation status.
The card carries out your existing health care power of attorney and aging-in-place directive. It does not replace them, and it is not a substitute for medical judgment.
How it works
- Complete it while you are well.Fill in your agent, backup agent, care manager and physicians. Do not wait for the emergency room.
- Give your agent copies.Three paper copies and a PDF. Keep one in the car or a go-bag.
- Your agent presents it on day one.The nurse and case manager see your goal before anyone proposes a facility. At the discharge meeting, your agent reads the goal aloud and works through the checklist.
- Line up help in advance.Choose a home-health agency and a backup caregiver, and make sure your financial agent or successor trustee can pay an aide the same day. A health care power of attorney does not write checks.
- Keep it current.Update it after any change of agent, address, plan or care manager, and after every hospital stay.
Download the materials
The card
One page, fillable on your computer. Type in the boxes and tick the checkboxes, then save your copy, or print it and write in pencil.
How to use it
A two-page memo for you, your agent and your care manager: when to complete the card, how to set it up, and what the agent does at the hospital.
Stay log and wallet card
One page to print. The agent keeps the log during any hospital stay, and the wallet card tells anyone who finds you who to call. Write on it by hand.
The card can be filled in on your computer in Adobe Acrobat Reader or a current Chrome, Edge or Safari browser; only the blank lines and boxes can be typed in. Nothing you type is sent to us. The memo, log and wallet card are for printing.
Make it part of your plan
The card works best alongside a signed health care power of attorney, HIPAA release, living will and aging-in-place directive. If you do not have them, or you are not sure they are current, we can help. For the larger picture, see the Aging in Place Planning Workbook and the Estate Planning Worksheet.
This page is general information, not legal or medical advice, and it does not create an attorney-client relationship. See our disclaimer.