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Navigating a Safe Discharge: A Guide for Medicare Beneficiaries

Transitioning from a hospital or skilled nursing facility (SNF) back home can be an overwhelming process. To do so under the restrictions and limitations of Medicare coverage can be even more difficult to

Here are some considerations for achieving a safe discharge under Medicare coverage that will ensure optimal recovery and minimize the risk of readmission

Understanding Medicare Coverage:

Before diving into the specifics of discharge planning, it’s important to understand Medicare coverage. Medicare Part A typically covers inpatient hospital and rehab stays, while Medicare Part B covers outpatient services and durable medical equipment (DME).

Key Players in Discharge Planning:

Effective discharge planning involves collaboration among various healthcare professionals, including physicians, nurses, social workers, therapists, and discharge planners. These individuals work together to assess the beneficiary’s needs and coordinate post-discharge care and services.  They are not ‘in charge’ of the plan, the beneficiary or their representative is.

Developing a Discharge Plan:

Creating a discharge plan begins with a thorough assessment of the beneficiary’s medical condition, functional status, and support system to identify any potential barriers to a safe discharge, such as the need for home modifications, assistance with activities of daily living, or rehab plans.

This plan may include referrals to rehab or home health services, medical equipment suppliers, or community resources.  Not all of these will be covered by Medicare, so you should ask whether a recommended service is covered by insurance or if private payment is required.

Follow-Up Care:

Follow-up appointments with primary care providers and specialists play a crucial role in post-discharge recovery. Beneficiaries should schedule these appointments before leaving the hospital or rehab and ensure they have transportation arranged. Remember once you’ve left the building, the hospital or rehab is no longer prescribing care, that role will be filled by the beneficiary’s primary care or specialist.

Transitioning to Home Health Services:

Many beneficiaries may require ongoing medical care and support at home following a hospitalization or rehab stay. Home health services, such as skilled nursing care, physical therapy or occupational therapy, can help facilitate a smooth transition and promote recovery.

The duration of these services is not open ended.  There will be a specific goal or purpose after which Medicare coverage will sunset and no longer cover costs.  Understand the goals of these therapies and prepare for providing the support needed when services end.  Before enrolling in any home health services, beneficiaries should understand any limitations or out-of-pocket costs.

Medication Management:

Beneficiaries should review their medication list with their healthcare providers to ensure accuracy and understand any changes made during their hospitalization.  Additionally, you should have a plan in place for obtaining prescription medications and managing the regimen at home.

Home Safety:

Ensuring a safe and supportive home environment is essential for a successful discharge. This may involve making modifications to the home, such as installing grab bars, ramps, or handrails, to accommodate the beneficiary’s needs. Family members or caregivers should also receive education on fall prevention and how to properly use Durable Medical Equipment (DME) like walkers, wheelchairs, commodes etc.

Advocating for Your Needs:

Throughout the discharge planning process, beneficiaries should advocate for their own needs and preferences. This may involve asking questions, expressing concerns, or seeking clarification on their rights under Medicare.

Navigating a safe discharge under Medicare coverage requires careful planning, by understanding Medicare coverage, actively participating in discharge planning, and accessing appropriate post-discharge care and services, beneficiaries can help maximize their recovery and minimize the risk of readmission.

Remember, you’re not alone in this process—reach out to your healthcare team or to Oasis Senior Advisors ( 914.356.1901 – 475.619.4123) for support and guidance every step of the way.

Oasis Senior Advisors


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Paul and Susan Doyle

Certified Senior Advisor®

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