Caregiver Questions for Discharge Planner DC
Before the Care Conference
The discharge planner meeting is your one chance to get everything on the table before your parent leaves the hospital. Most families go in with vague worries and come out with a plan they don't fully understand. These questions change that.
Ask them before the meeting, during the multidisciplinary care conference (which should include the attending physician, physical therapist, occupational therapist, nurse case manager, and social worker), and follow up in writing afterward.
Questions About Clinical Status
"Is my parent classified as inpatient or observation status?" This determines whether Medicare Part A will cover skilled nursing facility rehab. Observation time doesn't count toward the three-midnight qualifying stay. If the answer is observation, ask whether the physician will review the clinical documentation for a formal inpatient admission order.
"What skilled care does my parent still need?" Get specifics: wound care, IV medications, physical therapy, occupational therapy, speech therapy. Each one affects which post-acute setting is appropriate and what insurance will cover.
"What is the readmission risk?" Ask the physician directly. If your parent has a high risk of readmission within 30 days, that should influence how aggressive the follow-up monitoring plan is.
Questions About the Discharge Destination
"Is the recommended SNF or home health agency in-network for my parent's insurance?" This matters enormously if your parent has a Medicare Advantage plan or DC Medicaid managed care through AmeriHealth Caritas DC. An out-of-network facility can mean full out-of-pocket costs.
"Does the hospital have a financial relationship with the recommended provider?" Under CMS conditions of participation (42 CFR § 482.43), hospitals must disclose any ownership or financial interest in the home health agencies or skilled nursing facilities they recommend. Ask directly — the answer may explain why certain options are being emphasized over others.
"If you're recommending a skilled nursing facility, which ones have available beds?" The social worker must present a list of local facilities that accept your parent's insurance and currently have openings. Don't accept a single recommendation without seeing alternatives.
Free Download
Get the District of Columbia — Hospital Discharge Checklist
Everything in this article as a printable checklist — plus action plans and reference guides you can start using today.
Questions About Home Safety
"What durable medical equipment will my parent need at home?" Hospital bed, wheelchair, walker, shower chair, oxygen — get the complete list and confirm the physician has signed the orders. Medicare Part B covers 80% of approved DME.
"Has a home health agency been referred, and when will visits start?" If the plan includes skilled nursing or therapy visits at home, the referral should already be in process before discharge day. Get the agency name, the start date, and the visit frequency.
"What medical tasks will I need to perform?" Under the DC CARE Act, the hospital must provide you with written instructions and training on any medical tasks you're expected to handle — wound care, medication injections, catheter maintenance, feeding tube management. If you haven't received that training, say so now.
Questions About Medications
"Can I get the reconciled medication list today?" Ask the hospital pharmacist to compare the pre-hospital medications with the current prescriptions. Identify what's new, what's changed, what's been discontinued, and what was duplicated.
"Will all discharge prescriptions be ready at the pharmacy on discharge day?" If any require prior authorization from the insurance plan, that process needs to start now — not on the morning your parent is being wheeled to the car.
Questions About Follow-Up
"When should the first follow-up appointment be?" The answer should be within 7 to 14 days of discharge. If the discharge planner says "more than 14 days," push back — the 7- to 14-day follow-up significantly reduces readmission risk.
"Who do I call if something goes wrong at 2 AM?" Get a specific answer: the physician's after-hours line, the home health agency's on-call nurse, or a direct instruction to call 911 for specific symptoms.
Getting It All in Writing
Ask the discharge planner to document everything discussed in the written discharge summary. Verbal plans get lost. Written plans can be shared with the home health nurse, the follow-up physician, and other family members who share caregiving responsibilities.
The DC Hospital-to-Home Transition Toolkit includes a printable discharge conference question sheet and the complete post-discharge checklist — so nothing falls through the cracks between the hospital room and your parent's front door.
Get Your Free District of Columbia — Hospital Discharge Checklist
Download the District of Columbia — Hospital Discharge Checklist — a printable guide with checklists, scripts, and action plans you can start using today.