A Doctor's Framework for Hospital Discharge Decisions

Hospitals are one of the great paradoxes of American life. They teem with scientific and technological wonder, yet few if any want anything to do with them. They can and do often cure us, but they can (and do) also harm us. Hospitals are, of course, at absolute necessity, and yet when we or our loved ones need them, we must approach them with an abundance of caution and circumspection.

This is especially true for older adults, who research shows consistently report worse experiences with hospital stays than their younger counterparts. The first principle of a good hospital discharge is therefore to be discharged as soon as is safely possible. Beyond that, however, with hospitalizations often come with hundreds of questions. How much support will my parent or spouse need upon discharge? How do I access those supports? Under what circumstances would a stay in a short-term rehabilitation (also called a “skilled nursing”) facility be appropriate? And when would a return home with “home health services” (getting physical and occupational therapy at home) be more appropriate than short-term rehabilitation elsewhere?

These questions require very individualized answers: so much depends on someone’s specific medical needs upon discharge, their overall level of physical and cognitive function at the end of the hospitalization, and—here’s one that’s often overlooked (or under-appreciated) by medical teams—the degree of caregiving support in the home environment. This last one requires insight and advocacy from care partners. As I often counsel my patients and families: you know the home environment best, and you, therefore have the clearest view as to what level of support is and is not possible in that environment. And this is the second major principle of hospital discharge planning: the decision about where to go is not just about the care recipient. It must be made with a full understanding of the care environment, inclusive of the needs and capabilities of caregivers themselves.

Although each person’s situation is different, there are some additional general principles that can guide discharge planning toward the best possible outcomes. Several entities—the American Geriatrics Society, the John A. Hartford Foundation, among others—have promoted the “Four M’s of Age-Friendly Care” which are applicable not just to the hospital and post-hospital setting but in fact all environments. The Four M’s can help you frame questions—those to ask of yourself and those to ask of medical providers—in order to help optimal decision-making. These are:

Mobility

In what setting and with what supports would my loved one achieve the greatest mobility the soonest? Sometimes—for example after a severe hip fracture—intensive rehabilitation in a facility environment can maximize movement. Yet other times, going home with physical therapy coming to the home will be enough.

Mind

Unfamiliar places can be challenging, especially for those living with cognitive impairment. Going home instead of to a short-term facility may therefore be ideal for some.

Medications

Oftentimes medication regimens following a hospitalization are complex. Is there enough support in the home environment to ensure adequate medication management?

What Matters

Because hospitals can be impersonal places, this principle of age-friendly care often falls by the wayside. But what matters to a care recipient is critical to their well-being. We sometimes call this “goal-concordant care.” In short, preferences matter to our health. Sometimes, if there are pros and cons to both sides of a major decision, relying on someone’s preferences about where to be and what kind of care to receive can be the deciding factor.

In all, then, there are six principles to guide discharge planning:

1. Discharge as soon as possible
2. Think holistically about the care environment
3. Optimize mobility
4. Take care of the mind
5. Consider the impact of medication management
6. Listen to what matters most