Questions to Ask Your Hospital Discharge Planner in Tennessee

The discharge planner walks into your parent's hospital room, introduces themselves, and starts talking about "next steps." This conversation shapes everything that happens after your parent leaves — the quality of their recovery, the cost to your family, whether they end up back in the ER within a week. Most families nod along and accept whatever is offered. The ones who ask the right questions get dramatically better outcomes.

Questions About Hospital Status and Coverage

"Is my parent classified as inpatient or observation?" This is the single most consequential question in the entire discharge process. If the stay is classified as observation (outpatient), Medicare Part A won't cover skilled nursing facility rehab afterward — even if your parent spent multiple nights in a hospital bed. Ask this on the day of admission and every day after.

"If they're under observation, has the physician considered requesting inpatient reclassification?" The attending physician can advocate for an inpatient status change with the hospital's utilization review committee. If your parent has been under observation for more than two midnights, the clinical case for reclassification is stronger.

"Has the Important Message from Medicare been provided?" This document (Form CMS-10065) explains your parent's right to appeal the discharge. The hospital must deliver it within two days of admission. If you haven't received it, the hospital is out of compliance.

Questions About the Discharge Plan

"What is the specific, written discharge plan?" Tennessee Rule 0720-14-.05 requires hospitals to create a written discharge plan that identifies continuing physical, emotional, housekeeping, transportation, and social needs — and arranges to meet them before discharge. Ask for the plan in writing, not just a verbal summary.

"What medical tasks will we need to perform at home?" If your parent is going home with wound care, IV medication, catheter management, or any other clinical task, the hospital should demonstrate these procedures to the family caregiver before discharge. Ask for written instructions and a physical demonstration.

"Has home health been ordered, and which agency?" If your parent needs skilled nursing or therapy visits at home, the referral should be in place before discharge — not "in process" or "we'll send a referral." Get the agency name, their phone number, and the scheduled date of the first visit.

"Is DME being delivered before or after discharge?" Durable medical equipment — hospital beds, wheelchairs, walkers, oxygen — must be arranged and ideally delivered to the home before your parent leaves the hospital. If the DME supplier says delivery will take three days and discharge is tomorrow, that's a gap in the discharge plan.

Questions About Post-Acute Care Options

"What skilled nursing facilities are available, and can I see inspection reports?" The hospital must provide a list of available SNFs. Don't accept the first recommendation without checking the facility's record at internet.health.tn.gov — the Tennessee Health Facilities Commission publishes inspection reports, complaint history, and staffing data.

"Has the PASRR screening been initiated?" Before any nursing facility admission in Tennessee, a Pre-Admission Screening and Resident Review is required. If your parent has a history of mental illness, depression, or behavioral symptoms of dementia, the PASRR results affect which facilities can accept them.

"If my parent needs long-term care, has a TennCare CHOICES referral been made?" The discharge planner should be able to connect you with the local Area Agency on Aging and Disability for TennCare intake. If your parent may need ongoing care beyond what Medicare covers, this referral should happen during the hospital stay, not after discharge.

Questions About Follow-Up and Safety

"What are the specific follow-up appointment dates?" Not "follow up with your primary care doctor in two weeks." Actual scheduled appointments, with dates, times, and locations. If the appointments haven't been made, that's another gap in the discharge plan.

"What symptoms should bring us back to the ER?" Get a specific, written list of warning signs — not general advice. What temperature constitutes a fever that warrants emergency care? What level of pain or swelling around a surgical site is abnormal? What behavioral changes in a patient with dementia indicate a medical emergency?

"How do I arrange non-emergency medical transportation?" If your parent is on TennCare, non-emergency medical transportation must be scheduled through their Managed Care Organization at least 72 hours in advance. For unexpected transport needs, the MCO's broker has three hours (urban) to four hours (rural) to provide a ride once notified.

"Who is the single point of contact if something goes wrong after discharge?" Get a name and phone number — not a general hospital switchboard. You need someone who can quickly arrange a readmission, adjust medications, or escalate a home care issue in the first 72 hours after discharge, when readmission risk is highest.

The Tennessee hospital discharge transition toolkit includes a printable version of these questions organized as a bedside checklist, plus the follow-up scripts for each answer that flags a gap in the discharge plan.

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