When it comes to hospital-to-home transitions, hospital conferences or care plan meetings are one of the best and most critical tools you can use to ensure a smooth and successful discharge. Ensuring you ask the proper questions can help determine a positive outcome for the patient and reduce the likelihood of readmission.

At Senior Industry Services, we understand the pressure discharge planners face. There’s so much on your shoulders, ensuring you’ve given your patient, their loved ones and/or their caregivers adequate advice and information. Whether it’s a routine transition for a patient or a more complex one, we are here to support your goals and help you achieve them successfully. We aim to provide reliable clinical navigation for healthcare professionals working in the Central Texas region.

Here are some tips on what to ask during a care plan meeting to ensure your patient has a successful discharge and that their needs are being put first!

1. What is the patient’s current baseline—physically, cognitively, and socially?

Before you can determine where a patient is going, you need to understand where they’re starting from. Ask:

• What was the patient’s level of independence before admission?
• Are there any new cognitive or functional impairments?
• What kind of support system is available at home?

Determining this baseline will help determine if the patient is able to return home safely or if temporary rehabilitation or home health services are needed.

2. What are the new clinical needs that will require management in the home?

All discharge planning must anticipate a change in care. Ask: Are there wounds, new medications, or medical equipment (e.g., catheters, oxygen) to be managed?

• Is the caregiver or family trained for these needs?
• Will the patient need physical, occupational, or speech therapy at home?

If not addressed early, these gaps can result in complications or hospital bounce-backs.

3. Has the patient or family raised any concerns regarding the discharge plan?

Clinical readiness does not always equate to emotional readiness.

• Is the patient comfortable with going home?
• Have caregivers talked through concerns about managing care?
• Do they understand the discharge instructions?

Open communication uncovers hidden barriers and enables tailoring of support accordingly.

4. What’s the plan if things go wrong after discharge?

Prevent reactive care by asking:

• Who will the patient call if symptoms worsen?
• Is post-acute follow-up scheduled?
• Is the patient enrolled in transitional care or remote monitoring?

A safety net is necessary. Senior Industry Services can help coordinate post-discharge care navigation that reduces ER visits and readmissions.

5. Do we have the right partners in place for a safe transition?

Not all post-acute providers are created equal. Ask:

• Which home health agency or caregiver service will be following the patient?
• Are they qualified, available, and aligned with the goals of discharge?
• Who is responsible for communication when the patient arrives home?

Working with quality transition services, like those of Senior Industry Services, ensures that quality doesn’t suffer once the patient is out the door.

Final Thoughts: Don’t Leave Transitions to Chance

Hospital conferences are the beginning of every successful discharge. Ask the right questions, and you’re an advocate not just for faster discharges, but safer ones.

At Senior Industry Services, we help discharge planners uncomplicate the complex. If you need help coordinating services, educating caregivers, or managing a risky case, our Hospital-to-Home and Clinical Navigation solutions are designed to be your first call.

Written for Senior Industry Services by Lauren Hope Bartling

References:

15 questions to ask during discharge. Caregiving.com. (n.d.-b). https://www.caregiving.com/content/15-questions-to-ask-during-discharge