I’m Home, but the Discharge Plan Isn’t Working

If the Person Is Getting Worse While This Is Being Fixed

Don’t wait for the missing service to be resolved before addressing a medical change.

If the person has new or worsening symptoms, contact the clinician or service currently responsible for their care and describe exactly what changed.

Say:

“The discharge service still isn’t in place, and the person is getting worse. What should we do now?”

If the person is on hospice and the change may be part of the expected dying process, call the hospice 24-hour number.

If the person is in immediate danger, call 911.

Start With Whoever Was Supposed to Act

If the discharge paperwork names an agency, supplier, pharmacy, clinician, or other service, call them.

Ask:

• Did you receive the order or referral?
• Has it been accepted?
• Is anything missing or waiting for authorization?
• When will it happen?
• What should we do while we wait?

If they never received it or can’t provide the service, call the hospital discharge planner, case manager, social worker, or discharging unit.

If Home Health Never Started

Call the home-health agency.

Ask:

• Did you receive and accept the referral?
• What was ordered?
• When is the first visit?
• What care is needed until then?

If the agency can’t start soon enough, call the hospital discharge contact or current medical team.

Say:

“Home health hasn’t started. What’s the plan for the care the person needs until help is actually in place?”

Home health sends visiting nurses or therapists. It doesn’t send someone to stay and provide daily care.

If the person needs more hands-on care than home health provides, use I Need Help Caring for Someone →

If Equipment or Supplies Never Arrived

Call the supplier.

Ask:

• Did you receive the order?
• Has it been approved?
• What’s delaying it?
• When will it arrive?
• What should the person do safely until then?

If the supplier doesn’t have the order, call whoever ordered it.

Use I Need Medical Equipment or Supplies →

If a Medication Can’t Be Filled

Call the pharmacy and ask what’s stopping it.

Find out:

• whether the prescription was received
• whether the medication is available
• whether authorization is needed
• whether cost or coverage is the problem
• when the next dose is due
• what to do if it can’t be obtained in time

Contact the prescribing clinician if another prescription, authorization, or medication is needed.

Don’t wait until the next dose is missed to find out who can fix the problem.

If cost or access is the barrier, use I Need Help Paying for My Medications →

If Follow-Up Was Never Scheduled

If the discharge instructions say follow-up is needed but no appointment exists, call the clinician or office named in the plan.

Say:

“The discharge instructions say follow-up is needed, but no appointment was made. How soon does the person need to be seen?”

Ask who schedules it, what to do while waiting, and who to call if the person gets worse first.

“Follow up with your doctor” doesn’t mean an appointment exists.

If the Person Needs More Care Than the Plan Assumed

Tell the current medical team what’s happening.

Instead of:

“We can’t manage.”

Say:

“He needs two people to transfer now, and there’s only one person here.”

or:

“She can’t be left alone, and nobody is available overnight.”

Ask whether the person needs more help at home, different equipment, medical reassessment, or a different level of care.

A discharge plan has to work in the home the person has, with the help that’s available.

If Nobody Will Take Responsibility

Call the hospital discharge planner, case manager, social worker, or discharging unit.

Say:

“This was part of the discharge plan. It still hasn’t happened. Who owns this step now?”

If you’re passed to someone else, ask:

“Who should I call, and what do they need from you before I call?”

Write down:

• who you spoke with
• what they said
• who acts next
• when you should expect an answer

If the hospital’s part of the discharge plan remains unresolved, ask for patient relations. They can help escalate a hospital problem, but they don’t replace the agency, supplier, pharmacy, or clinician responsible for actually providing the missing service.

Don’t get passed between organizations without finding out who has the next action.

Before You Rely on the New Plan

Confirm:

• who owns the missing step
• what they agreed to do
• when it should happen
• what to do while waiting
• who to call if it still doesn’t happen
• who to call if the person’s condition changes

Find who has the next action, and make sure it happens.