Discharge Planning

Older persons who have been hospitalized often require some special planning for care after they are discharged. This care can range from assistance at home with the daily activities of living such as bathing, dressing, toileting, etc. to care in a rehabilitation facility or a nursing home. It is important for the patient and/or family to make early contact with the hospital’s Discharge Planner who has the responsibility to provide a plan for post-hospital care, often in coordination with the hospital Social Work Department. The New York State Department of Health regulations under Article 28, Part 405.9 have published the following Discharge Planning Guidelines:

  • Hospitals are required to have a coordinated discharge planning program to ensure continuity of care and the most effective utilization of hospital and community-based health and social services.
  • Hospitals are required to have written criteria for a high-risk screening system at time of admission to promptly identify patients who may need post-hospital care and planning.
  • All health care professionals play a role in assessing a patient’s post-hospital needs and developing an individualized comprehensive discharge plan consistent with the physician’s orders and patient’s needs.
  • Physicians have a key role in determining medical readiness for discharge and communicating this information to patients, families and other staff.
  • Discharge planning shall include patient and family participation in the decision-making process regarding post-hospital care and the selection of specific services.
  • Patients and family representatives shall be provided with information regarding the range of community services available.

Post-hospital care planning shall include consideration of the following types of services:

  1. Home care
    • certified home health agencies
    • long term home health programs
    • home attendant services
    • home delivered meals programs
    • electronic home monitoring and emergency response systems
  2. Skilled nursing facilities
    • short term rehabilitation facilities
    • long term care facilities
    • specialized facilities for head injury, terminal care, etc
  3. Hospice programs
  4. Outpatient care or treatment, including adult day service programs
  5. Respite care
  6. Community health, mental health and support service agencies/programs
  7. Provision of durable medical equipment as needed
  8. Information and assistance with entitlements such as Medicaid, Food Stamps, prescription subsidies, Social Security Disability, public assistance.

Hospitals must provide patients with a written discharge notice and a written discharge plan at least 24 hours before leaving the hospital. All health care services identified in the plan must be in place before the patient leaves the hospital. Patients seen in the Emergency Room but not admitted shall also be provided with discharge planning services.

A Discharge Plan provides the following information:

  • Describes the care and services you will need after discharge from the hospital
  • Describes how these services will be provided
  • Identifies how you can continue your recovery or maintain your health status

Under New York State law, the hospital must provide you with a copy of “Your Rights as a Hospital Patient in New York State.” This booklet includes “An Important Message from Medicare,” which explains what to do and how to appeal if you feel you are being discharged too soon or without an adequate care plan in place. Ask for this information if you do not receive it.

Beneficiary and Family Centered Care – National Coordinating Center
Contact this Center for any concerns regarding hospital discharge date, quality of treatment, and/or denial of admission.

New York State Department of Health
320 Carleton Avenue, Suite 5000
Central Islip, NY  11722
Hospital patients should contact the New York State Department of Health for assistance and information regarding any concerns, problems, or complaints that are related to their hospital stay and which cannot be resolved by a physician, staff, or social worker.