Discharge Planning

Get involved with discharge planning to make sure your family’s and loved ones’ needs are met

Discharge planning is the process that medical staff use to prepare for a person’s move from the hospital or rehabilitation program to home or another care setting. Social workers and/or case managers will help you and your loved one’s medical or rehabilitation team identify options and determine your loved one’s next step in treatment and care. Health insurance and the ability to cover the costs of care can play a large role in discharge planning.

Attend discharge planning meetings and don’t be afraid to speak up and ask questions

Moving from a hospital to a rehabilitation facility or back home can be emotional, exciting, overwhelming, and exhausting. Don’t be afraid to speak up and ask questions as part of the discharge planning process. If you believe that your loved one is not ready for discharge and should stay in the hospital, speak with your insurance provider or other coverage provider, as well as the social worker or case manager. In some situations, insurance companies will approve extended lengths of stay in a hospital if a person continues to make improvements. You may need to involve a lawyer to help advocate for your loved one.

Here are some questions you can ask the medical team. 

Discharge timing

• Who decides when my loved one is ready for discharge, and how is it decided?
• What can I do if I disagree with the decision to discharge my loved one?
• What factors can affect when my loved one is discharged?
• How much time in advance will we know that my loved one is being discharged?

Care after the hospital stay

• What are the different care options available to my loved one?
• What happens if the care option that is best for my loved one is not currently available?
• What can we do if we are unable to make our home ready to meet the care needs of our loved one?
• Where should my loved one get follow-up care? What type of specialists should they see?
• Where can I get a list of resources for support in my community, like my local brain injury association, case management, and home-based care?
• Is there information or training to help me learn how to:
  • Use the feeding tube?
  • Manage medications?
  • Assist with any physical or cognitive therapies?
  • Set up my home?
• What things do I need to watch for that require emergency care or should be reported to the medical team?

Keeping records

• How do I get a complete set of my loved one’s medical records?
• Is there a charge for getting medical records?

You can also download this checklist from the Understanding the Brain Injury Journey: A Practical Guide for Families.

Additional resources for discharge planning

• Pushing back against unsafe discharges
• Getting help paying for care
• Rehabilitation care
• Community-based treatment options
• Caring for a loved one at home

Compassionate answers. Real support. Every step of the way.

Contact the National Brain Injury Information Center at 1-800-444-6443 to speak to a specialist about:

• Help with care needs
• Legal and financial resources
• Services in your community