You've Been Discharged from the Hospital: Now What?

By Danielle Savage MD, Doc in your Corner
The period after discharge from the ER or hospital can be an especially confusing time, even more so after a prolonged or difficult hospital stay. Whether you are dealing with pain or worry after being admitted to the hospital for an acute (short-term) issue like a surgery, a new life altering diagnosis, a difficult road to recovery after a prolonged stay, a new disability or the need to provide support and care for a loved one who has become or is incapacitated, the time period after being discharged from the hospital can be confusing and de-stabilizing, with patients and their families unsure of who to turn to or what actionable steps to take.

In fact, this is one of the most dangerous time periods for patients in terms of their health—if the right support and guidance is not received in a timely fashion, patients often end up right back in the hospital back where they started. To combat this, Medicare plans generally cover a longer appointment with your PCP, called a “Transition of Care” appointment. This mostly applies to Medicare patients when it comes to billing and insurance payments, but in general can be applied to any person being discharged from an inpatient facility, since this is a particularly risky time period.

A Transition of Care (or TOC as it is called in your doctor’s office) appointment is meant to be a visit where the details of your hospital stay can be reviewed with your doctor or other licensed provider (such as an NP or PA) within a 7-14 day period from the day of discharge from the hospital. At this vital appointment, the provider can review notes and results from your hospitalization and any medication or treatment changes that were made while you were admitted. They can also follow-up on any test results that were not yet finalized before you were discharged and review these with you if applicable. This ensures that your provider can continue to prescribe the medications that were given to you during your stay if needed, and that you follow-up with any specialists or other providers that need to be further involved in your care.

Your PCP should often be the very first practitioner that you see after your discharge, in order to ensure that there is one person overseeing all of this and that all goes according to plan. Included in Transition of Care Appointments are discharges from:
● Inpatient acute care hospitals
● Inpatient psychiatric hospitals
● Inpatient rehabilitation facilities
● Long-term care hospitals
● Skilled nursing facilities
● Hospital admissions for “observation” / partial hospitalization
● Partial hospitalization at a community mental health center

Taking these steps upon or after your hospital discharge should help to simplify the process and ensure you get the care that you need:

1. Call your or your family member’s PCP office and let them know that you or your loved one was discharged from the hospital and is in need of a Transition of Care or Hospital follow-up appointment

**This is important so that the office schedules an adequate amount of time for the appointment and is able to obtain the appropriate hospital documents ahead of the appointment**

a. Let them know the name and location of the hospital as well as the date of discharge so that they may obtain records if they do not already have them
b. This appointment should technically be scheduled within 7-14 days of your discharge (per insurance requirements) for your health and safety—if they decline to offer an appointment within this time frame, politely discuss this medicare requirement with them or ask to speak to the office manager to ensure that you can get scheduled within this time period. Because this transitional period after a hospitalization can be so de-stabilizing, it is really important to be seen in a timely fashion to ensure that you remain stable and stay out of the hospital!

2. Call any other specialists that you were told to follow-up with to schedule an appointment as well (for example, if you had surgery during your hospital stay, you should also schedule a follow-up with the surgeon who performed your surgery)

3. Bring with you to your appointment:
a. All discharge documents from the hospital—this includes a discharge medication list, discharge summary with list of recommended specialists to follow-up with
b. Any test results that you have from the hospital

4. Questions to think about asking during your Transition of Care appointment:
a. “Should I continue taking the medications given to me by the hospital, or will you be making any changes to these?”

1. i. “Which medications should I continue, and which ones should be discontinued?”
2. ii. “Which medications will you be changing?”
3. iii. Request a copy of your updated medication list with any new or changed medications

b. “Which specialists do I need to follow-up with and are any more urgent than the others?”

1. i. If any appointments are urgent, I suggest asking your PCP if their office staff may be able to contact that specialist office in order to help prioritize you

c. “Am I entitled to any home health aide services that my insurance might cover based on my diagnosis?”

1. i. Sometimes the hospital has already requested for this and you may not know it. Check with your PCP to see if this is the case, as you want to ensure you are receiving any calls from the home health agency to schedule your visits.

d. “Am I entitled to or would I benefit from additional services like Physical Therapy (PT,) Occupational Therapy (OT), or speech therapy? Can these be done from my home, if I have difficulty with walking, movement or have no way of getting to appointments?”
e. “Are there any changes I need to consider making to my home to ensure my safety based on my diagnoses or new conditions, and can I receive prescriptions for these? (Medicare or Medicaid may cover in some instances)”

1. i. ie. handicapped ramps, shower seats, handle bars in the bathroom, stair lifts, hoyer lifts.

Remember that you and/or your loved ones should never feel like you are managing alone during this difficult time. Reach out to your primary care doctor or specialists if you are ever uncertain about what medications you should or shouldn’t be taking, what doctors you should be seeing, or any new symptoms that come up after you have been discharged!