Discharge planning — what to fight for before they come home

Disclaimer: This article provides guidance on discharge planning for elderly patients. It is not medical advice and does not replace discussions with your parent's medical team. Discharge planning decisions should be made collaboratively with healthcare providers, your parent, and your family based on your parent's medical needs and circumstances.

The doctor says your parent can go home tomorrow. You feel relief and dread simultaneously. Relief because they're recovering. Dread because you're looking at the stairs in your parents' home, the second-floor bedroom, the bathroom with no grab bars, and you're thinking about your parent's limited mobility after the stroke, and nothing feels remotely ready. The hospital social worker is asking when they're being discharged and whether they need equipment, but you haven't even thought through what they'll need. Discharge can feel rushed, under-planned, and terrifying.

Discharge planning is critically important. It determines not just whether your parent can physically manage at home, but whether they'll recover well, whether they'll stay safe, and whether you can manage the caregiving demands without burning out. The time when your parent is still in the hospital, before they're discharged, is your window to ask for what they need and to fight for the support that will make homecoming possible.

Understanding What Discharge Planning Means

Discharge planning is the process of preparing for your parent to leave the hospital and transition to care at home or in another setting. It includes determining what kind of space they'll be in, what medical care they'll need, what equipment will help them function, who will provide daily care, and how the transition will happen.

Discharge planning ideally starts early in the hospital stay, not on the last day. It involves your parent, the hospital medical team, social workers, and you. It's not something that's done to your parent. It's something done with your parent, with you as a important participant in the conversation.

What You Need to Know

Before your parent is discharged, you need to know their diagnosis and prognosis. What condition required hospitalization? Is it improving? What's the realistic trajectory? Will they continue to improve, stabilize, or decline?

You need to know what their functional status is and what it will likely be in the near term. Can they walk? How far? Do they need a walker? Can they use stairs? Can they bathe themselves? Can they use the toilet independently? If not, how much help do they need? These questions are uncomfortable, but they're essential.

You need to know what medical care they'll need at home. Will they need medications? How many and how complex? Do they need wound care? Physical therapy? Occupational therapy? Will they need monitoring of important signs like blood pressure or blood sugar?

You need to know what pain they're likely to have and what pain management plan is in place. Are there medications? Are there limitations on activity? How will pain be managed as they recover or as their condition changes?

You need to know about any infection risks, dietary changes, activity restrictions, or other precautions they should follow at home.

Assessing Your Home

Before discharge, honestly assess whether your parent can physically manage at home. Walk through the home from their perspective. Can they get from the front door to the bedroom? Are there stairs? How many? Can they work through them safely with their current mobility? What about bathrooms? Can they get to the toilet safely? Can they bathe safely?

Look at the bedroom. Can they get into and out of bed safely? Is there space for a walker or wheelchair if needed?

Look at the kitchen. If they'll need to prepare any food, can they access the stove, refrigerator, and cabinets safely? Can they carry items without dropping them?

Look at the bathroom. Are there grab bars? Is the shower or tub accessible? Can they manage toileting safely?

Look at lighting. Are there lights in hallways? Can they turn them on and off easily? Poor lighting is a major fall risk.

Look at clutter. Trip hazards like extension cords, throw rugs, or items on the floor need to be removed.

If your parent's home isn't safe given their current mobility and function, you have choices. You can modify the home before discharge. You can arrange for temporary skilled nursing care at home. You can arrange for a temporary stay in rehab or a facility. Or you can recognize that home might not be the right place for them right now and explore other options.

Home Modifications That Matter

Grab bars in the bathroom prevent falls. They should be installed securely in the shower or tub and near the toilet. These are not optional if your parent has balance problems or reduced mobility.

A raised toilet seat makes using the toilet easier for people with hip or knee problems or limited mobility. Some include grab bars attached.

A walk-in shower or a shower chair allows bathing safely for people who cannot stand in a regular shower. These are more complex to install but worth considering.

Ramps or a small step stool at entrances help people with mobility limitations get in and out of the house.

Bed rails or transfer handles help people get into and out of bed safely.

Improved lighting, removing trip hazards, and clear pathways reduce fall risk.

A first-floor bedroom or temporary bed setup eliminates the need to work through stairs.

These modifications can be expensive, but fall prevention is important. Sometimes they're covered by insurance if ordered by a physician. Ask the hospital social worker about this.

Getting Support at Home

Depending on your parent's medical needs, they might benefit from home health services. Nurses can monitor wounds, change dressings, administer medications, and watch for complications. Physical and occupational therapists can help with movement and function. Social workers can help coordinate care.

Home health requires a doctor's order. Ask before discharge whether your parent would benefit from it. Insurance often covers home health when it's medically necessary.

Some people need in-home caregivers to help with daily activities. These might be informal caregivers (family and friends) or paid caregivers. Figure out who will help your parent with bathing, dressing, toileting, meals, and other daily needs.

Adult day programs provide social connection and activities while providing respite for full-time caregivers. Some programs also provide lunch and medication management.

Community resources like meal delivery programs, transportation services, or friendly visitor programs help support your parent at home.

The hospital social worker can help connect you with these resources. Take advantage of their knowledge and expertise.

Managing Medications at Home

Your parent will likely be on multiple medications after hospitalization. Get a clear list of what they're taking, what dose, and when they should take it. If they were taking medications before hospitalization, make sure you know whether those continue, whether any were stopped, and whether any new medications were added.

Discuss with the doctor or pharmacist about potential side effects, what to watch for, and what symptoms warrant a call to the doctor.

Make sure your parent, or you if you're managing medications, understands how to take them. Are they with food or without? Do any need to be taken at specific times? Can they be taken together or should they be separated?

Set up a system for managing medications. A pill organizer, a chart on the refrigerator, or phone reminders all help ensure medications are taken correctly.

If your parent has difficulty taking medications or remembering when to take them, home health nurses can help. Sometimes they administer medications or supervise to make sure they're taken correctly.

Arranging Follow-Up Care

Before leaving the hospital, appointments should be scheduled with the appropriate follow-up doctors. Usually this is the doctor who admitted your parent and any specialists who need to continue care.

Get the appointment details in writing. Know the date, time, location, and doctor's name. Know what testing or preparation is needed before the appointment.

Arrange transportation if needed. Can you drive your parent? Do they need medical transportation? Can family or friends help?

Confirm that medical records will be sent to the follow-up doctors before the appointment. You might need to request this explicitly.

If your parent is concerned about attending appointments or remembering them, write it on a calendar in large print. Set phone reminders. Do whatever it takes to ensure they attend.

The Conversation About Goals

Before discharge, have a conversation about what matters most to your parent. Are they hoping to recover enough to live independently? Is comfort their top priority? Do they have wishes about what interventions they do or don't want if their condition changes?

This conversation is hardest when you don't want to face what might be coming. But it's essential. If your parent has clear wishes about their care, you can ensure those wishes are respected even if circumstances change.

Discuss their fears. What worries them about coming home? What concerns do they have about recovery? What help do they think they'll need? Their perspective matters and might identify needs you haven't considered.

Fighting for What They Need

Sometimes discharge plans are made quickly without adequate consideration of safety or support needs. If you feel the discharge plan isn't adequate, speak up. Ask for a family meeting with the medical team, social worker, and case manager. Say what you're concerned about. Ask for the help your parent will need.

If your parent isn't medically ready to go home but the hospital wants to discharge them, you have the right to request a continued stay or to arrange for rehabilitation first. Insurance might not pay for this, but your parent's safety matters.

If you cannot physically manage caregiving in the situation they're being discharged into, say so. Ask what support you need. Ask what's possible. Sometimes just articulating the problem helps find solutions.

If discharge planning feels rushed or inadequate, ask for an extension or a delayed discharge to give time for proper planning.

After Discharge: The First Days

The first few days at home are vulnerable. Your parent is adjusting to being out of the hospital. They're likely to be tired, to have pain, and to need support. Be present. Watch for complications like infection, bleeding, or changes in mental status.

Make sure your parent is taking medications correctly. Make sure they're eating and drinking. Make sure they're resting. Make sure they're following activity restrictions.

Have the phone numbers for your parent's doctors and the hospital easily accessible. If something goes wrong, you need to be able to reach help quickly.

This is when all the planning becomes real. If the home modifications were made, are they helping? If home health nurses are visiting, are they adequate? If you're managing caregiving, can you sustain this? This is the moment when you learn whether the discharge plan was actually workable.

The Big Picture

Discharge planning is your chance to advocate for the support your parent will need at home. It's your chance to prevent a quick return to the hospital because the discharge plan was inadequate. It's your chance to set up a system that supports recovery and safety.

Take it seriously. Ask questions. Speak up about concerns. Accept help. Modify the home. Arrange support services. Do the work required to make coming home safe and manageable. Your parent's recovery depends on it. Your own wellbeing depends on it. The time to do this work is while they're still in the hospital, not after you've brought them home and realized nothing is ready.

Disclaimer: This article provides guidance on discharge planning for elderly patients. Medical decisions and discharge planning should always be made in consultation with qualified healthcare providers, your parent's medical team, and based on your parent's specific medical condition, needs, and preferences. This guidance does not replace professional assessment or recommendations from healthcare providers.