Hospital Discharge: The Checklist That Prevents a Readmission

Ask for the discharge planner on day one

Do not wait to be told when discharge is coming. Ask early who the case manager or discharge planner is, and say clearly what support exists at home — including that there may be none during the day. Plans built on an assumption that "family will manage" are the ones that fail.

Settle these before discharge day

• Who is physically present at home for the first 72 hours, and overnight.
• Whether stairs, the bathroom or the bed are usable as the home is today.
• Equipment: walker, wheelchair, bedside commode, shower chair, hospital bed — ordered and delivered, not promised.
• Medication list reconciled against what is already in the medicine cabinet, with the old bottles removed.
• Prescriptions filled before you leave, not on the way home.
• Follow-up appointments booked, with transportation arranged.
• Whether home health has been ordered, and when the first visit will be.
• Written instructions on wound care, weight limits, diet and activity restrictions.

The first 72 hours

This is when readmissions are set in motion. Keep it simple: someone present, medications given exactly as written, fluids offered regularly, short frequent movement rather than long stretches in bed, and a written log of temperature, pain, intake and bowel function. A log turns "he seems off" into information a nurse can act on.

Warning signs that warrant a call, not a wait

• Fever, chills, or a wound that becomes red, hot, swollen or foul-smelling.
• New or worsening shortness of breath, chest pain, or confusion.
• Unable to keep fluids down, or no urine output for many hours.
• Sudden weight gain over a day or two in heart failure.
• A fall, even without obvious injury.

When in doubt, call the physician's office. For chest pain, stroke symptoms, or difficulty breathing, call 911.

Where non-medical care fits

Home health provides skilled visits. What fills the rest of the day is help with bathing, dressing, meals, medication reminders, transfers and watching for the warning signs above. We can often start within a day or two of a discharge, including weekends, and we coordinate with the home health schedule so the person is not alone for the parts of the day that matter.

For hospital teams

Case managers and discharge planners can send a referral through our secure referral portal and reach a coordinator directly for same-day capacity.