hospital-discharge-planner

Audits hospital discharge orders, decodes paperwork, decides post-acute setting with Medicare rules, plans first 72 hours at home, and creates caregiver hand...

Discharge day is the most dangerous handoff in medicine: the patient moves from 24/7 monitored care to a home setup decided in a 15-minute conversation, on a medication list that may have been rewritten twice that week, with follow-up appointments that "someone will call to schedule." Readmissions within 30 days run ~15% — and most discharge harm is preventable with questions asked BEFORE the wheelchair reaches the lobby.

When to Use

• Discharge is announced today/tomorrow — before the papers are signed
• Deciding post-acute setting: home vs rehab (SNF/IRF) vs assisted living respite
• A Medicare patient crossing the 3-night observation-vs-admission line (SNF coverage depends on it)
• Setting up the home landing zone: meds, equipment, bedroom floor, first 72 hours of caregiving
• Second opinion on "ready for discharge" when the family disagrees
• Caregiver handoff between family members / hired help

Don't use for: disputing an inpatient admission actively needed (ask for the medical team); discharges to hospice (a different, palliative playbook — ask for the hospice coordinator); pediatric NICU protocols (hospital-specific). If the patient is unsafe to be discharged, say the words "I want to file an appeal under MOON/IMD" — see references.

The Method

1. audit — the 7-question discharge-order audit asked BEFORE signing: (1) meds reconciled against the home list — every change named and why; (2) follow-up appointments BOOKED with dates, not "will call"; (3) new equipment/services ordered AND trained; (4) red-flag symptoms for THIS condition with who-to-call numbers; (5) activity/wound/diet orders in writing; (6) who is the responsible clinician between now and follow-up; (7) is the destination actually ready (person + meds + bed level + ride)? Any "no" = a gap to close before the wheelchair moves.
2. paperwork — decode the document stack: After-Visit Summary (AVS) vs discharge instructions vs Notice of Medicare Non-Coverage (NOF/CMS-10123) vs the MOON observation notice; which pieces the next-of-kin should keep; where the diagnosis and med list live for the next ER visit (pro tip: photo of every page).
3. postacute --nights 4 --setting home-with-help — the setting decision: home-with-help vs SNF vs IRF with the Medicare mechanics (3-night inpatient rule for SNF; days 1–20 fully covered, days 21–100 daily coinsurance 2026, the "therapy cliff" where SNF stops progress-gains); home-health eligibility (homebound + skilled need); what "observation status" breaks.
4. landing --help-hours 8 --floors 1 — the 72-hour landing plan: med-schedule build (reconciled list → times grid, first dose timing), bedroom-floor setup (bathroom distance, night path lighting, chair height), caregiving coverage vs your hours, the red-flag sheet on the fridge, first follow-up transport.
5. handoff — generates the caregiver handoff card (conditions, meds with times, allergies, red flags + numbers, code status, PCP/specialist) and the case-manager question list.

Run python3 scripts/discharge_planner.py <cmd> --help.

Judgment Rules

• Discharge is a negotiation, not a verdict. If the patient is unsafe (can't transfer, no caregiver, uncontrolled pain), say it out loud and ask for: case manager, discharge planner, or a delayed discharge. Filing the NOF appeal fast-forwards the conversation.
• "Someone will call to schedule" = not booked. Unbooked follow-up is the #1 discharge gap; get the appointment date in writing, or call from the hospital room before leaving — with the insurance card, hospital scheduling desk does it faster than you will later.
• The med list is the danger zone. Hospitals restart chronic med lists from scratch; home meds get dropped or duplicated (especially blood thinners, diabetes meds, diuretics). Reconcile line by line against the HOME pharmacy list; ask "start/stop/changed?" per drug.
• Observation status quietly costs $ thousands. Medicare observation ≠ inpatient: no SNF coverage, different Part B cost sharing. Ask DAILY "what is the patient's status today?" and if observation, ask the case manager to reconsider (or request Beneficiary and Family Centered Care review).
• Home-health orders must exist before you leave. "We'll order home health" verbal = nothing; get the agency name and the order in the AVS.
• The 72-hour landing zone fails on logistics, not medicine: nobody picked up the new prescription, the bedroom is upstairs, the caregiver shifts don't cover night wander-risk. landing exists to make those explicit.
• Photo every page of the paperwork. The next ER/urgent visit runs 10× smoother with the AVS on your phone.

Common Pitfalls

1. Signing discharge papers as-is without the 7-question audit — gaps surface at home at 11 pm, not in the suite.
2. Assuming follow-up is scheduled. It isn't until it has a date and a name.
3. Missing med reconciliation: home beta-blocker "disappeared" from the new list; duplicate PPIs; insulin scale changed without the family being told.
4. Observation status discovered AFTER the SNF bill — nobody asked status during the stay.
5. Fighting for SNF days 21–100 without progress documentation — therapy notes are the currency; ask for them weekly.
6. The landing zone built around an optimistic mobility estimate — plan for the discharge-day reality, upgrade later.
7. No red-flag sheet — every caregiver invents their own "should we call?" threshold; the sheet standardizes it.
8. Ride home arranged for the wrong time ("discharge at 10" often means 16:00) — ask for the realistic window the morning of.

Verification Checklist

• 7-question audit asked; every gap has an owner and a time
• Med list reconciled line-by-line vs home pharmacy list; changes understood (start/stop/dose) in writing
• Follow-up appointments: dates + names in hand (not "will call")
• Home health / equipment / DME: ordered, named, trained
• Patient status confirmed (inpatient vs observation) in writing
• Post-acute setting decided with the Medicare math understood
• Red-flag sheet printed and on the fridge; numbers verified
• 72-hour landing plan: meds picked up, bedroom floor set, night coverage assigned, first-visit transport booked
• Every paperwork page photographed
• Handoff card given to every caregiver (family + hired)

One-Shot Recipe

Mom, 78, hip replacement, day 3, discharge tomorrow, Medicare Advantage, family covering evenings:

bash

python3 scripts/discharge_planner.py audit
python3 scripts/discharge_planner.py paperwork
python3 scripts/discharge_planner.py postacute --nights 3 --setting home-with-help
python3 scripts/discharge_planner.py landing --help-hours 6 --floors 1
python3 scripts/discharge_planner.py handoff --patient "Mom 78, hip replacement" \
    --contact "Ana (daughter) 555-0100"

Ask the audit questions at today's rounding; get the PT follow-up and home-health order INTO the AVS before the wheelchair moves.