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The 7 Steps of Discharge

The 7 Steps of Discharge

Hooray! You or your loved one has been working hard in rehab and the goals have been met.  Now there’s only a few last steps between you and home. This is going to be a big transition, but the good news is since you or your loved one were admitted, a team of professionals began working on your discharge. It’s not just your goal to get home safely, it’s also our goal for you to get home safely.  When you or your loved one was admitted to the SNF (skilled nursing facility) for rehab, your family should have met with a team of leaders from the facility to discuss how the patient was doing at the time of admissions, what the family’s goals are for the patient, and how the SNF can work with you and your family to meet those goals. Families will often wonder how a SNF decides someone is ready to discharge or about the different steps involved, so in an effort to be more transparent, we’ve compiled a general list of steps that go on behind the scenes to prepare you and your family for a safe discharge home.

Step 1- Weekly Meetings

Every week an interdisciplinary team meets to talk about all of the rehab patients. This team is comprised of Social Services, Nursing, Rehab, Medical Records, Activities and MDS. They discuss how the patient is progressing in all different aspects of care. They cover a lot. They also talk about what the patient’s insurance is willing to cover, how the patient can best be served within those premises, and what improvements the patient’s primary care physician is looking for. This happens once a week and as patients improves, with all of these different factors in mind, this team makes recommendations for discharge.

Step 2- Coordinating Supplies & Services

Technically, according to Medicare guidelines, Social Security only has to give a patient a 72 hour notice that they will be discharged. However most places want to start this conversation much earlier to make sure the patient is prepared and comfortable once it’s time to go home. Social Services is responsible for making sure your transition home is safe. They coordinate whatever new services and/or equipment you may require. Some of this stuff can be easily taken care of with one phone call, while other things, like a hospital style bed, may take weeks to coordinate. That’s why they’re getting started right away. Social Services figures out what home life looks like for the patients and starts the discharge conversation with family right away. Who will be helping at home? Does your home need upgrades to be safer for your new needs? Will you need new equipment? Do you need to have caregivers helping during the transition home? There’s a bunch of questions Social Services is looking at to make sure you’re going home and staying home. If you’re going to need the help of a home health agency after discharge, which many people do, Social Services also wants to get that coordinated right away so you have time to meet with the different providers and take your time in the decision making process. In most cases, the therapy department will also do a home visit to make recommendations on new equipment and home upgrades, and those recommendations are carried out through Social Services.

Step 3- Identify a date and inform the patient

By the time discharge comes, you’ll probably already have had several conversations with Social Services about your time to go back home. That won’t make it any less exciting when you receive that formal letter of discharge.


Step 4- Coordinating with Doctors and Pharmacy

At this point, Social Services and Nursing will start the formal discharge process with your primary care physician. Every physician handles this a little differently, but from a SNF standpoint, what we will need are the orders from the physician saying you are safe to return home. If you have medications, Nursing will take care of coordinating everything with the pharmacies and giving you the run down how to safely take the medications once you’re home.

Step 5- Coordinating with Insurance

The SNF you are staying at will be in charge of notifying Medicare that the patient will no longer be needing our services.

Step 6- Bye!

You pack up all your belongings and go home- you did it! Your home should be safe and ready for you with extra care for that transitional period. All of your medical stuff should be coordinated by Social Services and Nursing so that once you’re home, it’s time to relax!

Step 7- Just Checking In

We’re probably going to call you. No matter how much we prepare, sometimes things happen and it’s in no one’s best interest if you end up back in the hospital. For that reason, most SNF’s will give you a call during the first week, second week, and third week just to check up and make sure your recovery is still going well, and to answer any questions. We’re not trying to bug you, but a preventative phone call is much better than a potential trip back to the ER.

And that’s discharge! Obviously like every patient, every case is unique, but this outline can give you a good, general idea of what to expect. We do have a couple notes regarding a few common questions that pop up.

  • Families going to Assisted Living: This is the standard discharge for someone returning to their home. If you or your loved one will be transitioning to an Assisted Living Facility, that takes a little more coordination from Social Services. They will help you find a facility that meets your needs, and that facility will come in to assess you or your loved one to make sure they can properly care for you.
  • You don’t have to leave super early: Many people think discharge means you have to leave first thing in the morning. It makes sense, that’s what happens when we stay anywhere else like hotel, but that’s not the case at a SNF. If you’re at Vienna, you can discharge any time after 10:30AM. So if your ride home isn’t available until the afternoon or evening, that’s totally fine. You will however need to leave by midnight on the day of your discharge. Otherwise you will have to pay out of pocket for another full day.
  • Discharge does not mean you’re being kicked out! Discharge means as far as your insurance is concerned, you’ve either a) met your goals as identified by the SNF and your family at time of admissions b) can walk a household distance, which means you should be safe to be in your own home with a home health provider or c) you’ve hit maximum potential that this form of therapy can provide. Once your insurance has decided you’ve achieved one of these three markers, they will no longer pay for your care at a SNF. So you’re welcome to stay but you will probably have to pay out of pocket.
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