What exactly does the patient need at home?
Ask for the list in writing: medications with doses and times, equipment, treatments, frequency of nursing visits, and which tasks the family must perform. If the answer is unclear, ask again until the family can repeat it back.
Who writes the orders, and who reviews them?
Skilled nursing at home follows a physician's orders and a written plan of care. Ask which physician will sign the orders and which agency will review them, and ask for the medication and treatment lists to be reconciled before discharge.
What will happen on days one through seven?
Medically complex patients are most fragile in the first week home. Ask about scheduled nursing visits, who to call at 2 a.m., and what warning signs should trigger a call, an urgent visit, or a return to the hospital.
Who coordinates the equipment and supplies?
Ventilators, feeding pumps, infusion pumps, oxygen, and wound supplies each have a supplier, a delivery date, and a set of instructions. Ask who is responsible for making sure everything arrives before the patient does.
What is the payer situation?
Ask the case manager which payer will cover home care, whether authorization is in place, and what the family's out-of-pocket exposure could be. Determining this before discharge prevents a coverage surprise later.
Is the home actually ready?
A hospital bed needs floor space, equipment needs power and placement, and hazards need to be cleared. Ask what the discharge team recommends for the specific patient, and give the family time to prepare.
Your Next Step
Talk Through the Discharge Plan
Liberty's care team can review the patient's needs with the family and the discharge planner before the discharge date, at no cost.
Talk Through the Discharge Plan