Planning. Checklist: For patients and their caregivers preparing to leave a hospital, During your stay, your doctor and the staff will work with you to plan for.

304 KB – 6 Pages

PAGE – 2 ============
Name:Reason for admission: 2During your stay, your doctor and the staff will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. You and your caregiver can use this checklist to prepare for your discharge. Instructions: Ł Use this checklist early and often during your stay. Ł Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. Ł Check the box next to each item when you and your caregiver complete it. Ł Use the notes column to write down important information (like names and phone numbers).Ł Skip any items that don™t apply to you. Action items Care after dischargeAsk where you™ll get care after you™re discharged. Do you have options (like home health care)? Tell the staff what you prefer. If a caregiver will be helping you after discharge, write down their name and phone number. Your healthAsk the staff about your health condition and what you can do to get better. Ask about problems to watch for and what to do about them. Write down a name and phone number of a person to call if you have problems. Notes

PAGE – 3 ============
Action items Use fiMy drug listflon page 5 to write down your prescription drugs, over-the-counter drugs, vitamins, and herbal supplements. Review the list with the staff. Tell the staff what drugs, vitamins, or supplements you took before you were admitted. Ask if you should still take these after you leave. Write down a name and phone number of a person to call if you have questions. Recovery & support Ask if you™ll need medical equipment (like a walker). Who will arrange for this? Write down a name and phone number of a person you can call if you have questions about equipment.Ask if you™re ready to do the activities below. Circle the ones you need help with, and tell the staff: Ł Bathing, dressing, using the bathroom, climbing stairs Ł Cooking, food shopping, house cleaning, paying billsŁ Getting to doctors™ appointments, picking up prescription drugs Have support in place that can help you. See fiResourcesfl on page 6 for more information.Ask the staff to show you and your caregiver any other tasks that require special skills (like changing a bandage or giving a shot). Then, show them you can do these tasks. Write down a name and phone number of a person you can call if you need help. Talk to a social worker if you™re concerned about how you and your family are coping with your illness. Write down information about support groups and other resources. Talk to a social worker or your health plan if you have questions about what your insurance will cover and how much you™ll have to pay. Ask about possible ways to get help with your costs. Notes3

PAGE – 4 ============
Action items Ask for written discharge instructions (that you can read and understand) and a summary of your current health status. Bring this information and your completed fiMy drug listfl to your follow-up appointments. Use fiMy appointmentsfl on page 5 to write down upcoming appointments and tests. For the caregiver Write down and discuss with staff any questions you have about the items on this checklist or on the discharge instructions.Can you give the patient the help he or she needs? What tasks do you need help with? Do you need any education or training? Talk to the staff about getting the help you need before discharge. Write down a name and phone number of a person you can call if you have questions. Get prescriptions and any special diet instructions early, so you won™t have to make extra trips after discharge.NotesMore information for people with Medicare If you need help choosing a home health agency or nursing home: Ł Talk to the staff. Ł Visit to compare the quality of home health agencies, nursing homes, dialysis facilities, inpatient rehabilitation facilities, and hospitals in your area. Ł Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. If you think you™re being asked to leave a hospital or other health care setting (discharged) too soon: You may have the right to ask for a review of the discharge decision by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) before you leave. A BFCC-QIO is a type of quality improvement organization (a group of doctors and other health care experts under contract with Medicare) that reviews complaints and quality of care for people with Medicare. To get the phone number for your BFCC-QIO, visit , or call 1-800-MEDICARE. You can also ask the staff for this information. If you™re in a hospital, the staff should give you a notice called fiImportant Message from Medicarefl, which contains information on your BFCC-QIO. If you don™t get this notice, ask for it. For more information on your right to appeal, visit . 4

PAGE – 5 ============
5My drug list Filled outon: _________________Use the space below to list all prescription drugs, over-the-counter drugs, vitamins, and herbal supplements you take. Include the name of the drug, what it™s for, how often you take it, and how and when you take it. Review this list with the staff. If you have Medicare and limited income and resources, you may qualify for Extra Help to pay for your Medicare prescription drug coverage. For more information about Extra Help, visit .My appointmentsUse this space to write down th e dates and times of your upcoming appointments. Include any appointments and tests you may be getting, as well as any necessary phone numbers.

PAGE – 6 ============
Resources The agencies listed here have information on community services, (like home-delivered meals and rides to appointments). You can also get help making long-term care decisions. Ask the staff in your health care setting for more information. Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs): Helps older adults, people with disabilities, and their caregivers. To find the AAA or ADRC in your area, visit the Eldercare Locator at, or call 1-800-677-1116. Medicare: Provides information and support to caregivers and people with Medicare. Visit Long-Term Care (LTC) Ombudsman Program: Advocates for and promotes the rights of residents in LTC facilities. Visit Medicare Patrol (SMP) Programs: Works with seniors to protect themselves from the economic and health-related consequences of Medicare and Medicaid fraud, error, and abuse. To find a local SMP program, visit for Independent Living (CILs): Helps people with disabilities live independently. For a state-by-state directory of CILs, visit Technology Assistance Project: Has information on medical equipment and other assistive technology. Visit, or call 1-703-524-6686 to get the contact information in your state.National Long-Term Care Clearinghouse: Provides information and resources to plan for your long-term care needs. Visit Council on Aging: Provides information about programs that help pay for prescription drugs, utility bills, meals, health care, and more. Visit Health Insurance Assistance Programs (SHIPs): Offer counseling on health insurance and programs for people with limited income. Also help with claims, billing, and appeals. Visit, or call 1-800-MEDICARE (1-800-633-4227) to get your SHIP™s phone number. TTY users can call 1-877-486-2048. Medicaid: Helps with medical costs for some people with limited income and resources. To find your local office, visit, or call 1-800-MEDICARE. You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to ˜le a complaint if you feel you™ve been discriminated against. Visit , or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048. Paid for by the Department of Health & Human Services. CMS Product No. 11376 Revised March 2019

304 KB – 6 Pages