Care Playbook
Hospital Discharge Is Coming - What Should We Ask?
Use this playbook to prepare for discharge, understand care needs, clarify medication changes, plan the first night, and avoid unsafe transitions.
Use as a working checklist. Complete what is useful now and return when the situation changes.
Important discharge safety note
If the person may be medically unstable, in immediate danger, or unsafe to leave the hospital without support, speak with the care team immediately.
This playbook does not replace medical discharge planning.
Who this playbook is for
- Families preparing for hospital, rehab, skilled nursing, or emergency department discharge.
- Caregivers who need to plan the first night and first week.
- Long-distance family members trying to clarify equipment, medication, and follow-up needs.
Common triggers
Quick situation intake
These answers personalize the callouts and summary. They do not block access to the playbook.
What to do now
What to do in the next 24 hours
What to do this week
What to document
These fields feed the shareable Family Care Plan Summary.
Who to call
Hospital discharge planner or case manager
Call when
Call when discharge destination, equipment, home health, rehab, or coverage is unclear.
What to say
We need a safe discharge plan. What care is required, what equipment is needed, what medications changed, and what would make home unsafe?
Doctor or nurse
Call when
Call when symptoms, medication changes, wound care, pain, or warning signs are unclear.
What to prepare
Medication list, new symptoms, equipment needs, and specific first-night concerns.
Home care agency
Call when
Call when the person needs help at home with bathing, toileting, transfers, meals, supervision, or caregiver relief.
What to prepare
Start date, schedule needs, tasks needed, mobility needs, and backup plan.
Family task owners
Call when
Call when the plan depends on family support after discharge.
What to prepare
A short list of tasks, owners, backups, and the first 72-hour plan.
Escalation triggers
- If discharge is today or tomorrow and caregiver coverage is not ready, ask for a safe discharge plan now.
- If the person is expected to be home alone with multiple first-night risks, ask the team to reassess the plan.
- If equipment, medication instructions, or after-hours contact is missing, clarify before leaving.
Set a suggested review date
3-7 days after discharge
Suggested review date: June 3, 2026
Generate care summary
Discharge Prep Summary
Send the intake, documentation, checked actions, recommended tools, questions, and review date to the Family Care Plan Summary.
Kefiw Discharge Prep Summary Date created: May 27, 2026 Suggested review date: June 3, 2026 Situation intake Where is the person now?: Not entered Where are they expected to go?: Not entered When is discharge expected?: Not entered Were medications changed?: Not entered Is equipment needed?: Not entered Is a caregiver ready and trained for the first night?: Not entered What is the biggest first-night concern?: Not entered Documentation Expected discharge date: Not entered Discharge destination: Not entered Medication changes: Not entered Equipment needed: Not entered First-night plan: Not entered After-hours contact: Not entered Follow-up appointments: Not entered Completed actions None checked yet Recommended next steps - Ask the first-night question before discharge. - Open the Medication Change Log. - Start the Care Needs Checklist. - Estimate home care or nursing home cost if added support may be needed. - Generate a discharge prep summary for family and providers. Questions to ask - What care must happen during the first night? - What medications are new, stopped, changed, or unclear? - What equipment must be delivered before arrival? - Who do we call after hours? - What would make home unsafe? Recommended Kefiw tools - Care Needs Checklist: Review what daily support discharge requires. - Medication List and Change Log: Track new, stopped, changed, and unclear medications. - Home Care Cost Calculator: Estimate paid help after discharge home. - Nursing Home Cost Calculator: Estimate rehab or nursing home cost scenarios. - Family Care Budget Calculator: Add new supplies, home care, transportation, and family support costs. Family script We are not refusing discharge. We are asking for a safe plan. We need to know what care is required, who will provide it, what equipment is needed, and who to call if the plan fails.
You have a starting plan.
You documented what happened, identified the next care steps, and selected tools to continue planning.
Related guides
Review and scope
Recommended reviewer type: Clinician, Nurse reviewer, Geriatric care manager, Patient safety reviewer. Last reviewed: April 30, 2026. Next scheduled review: annual update cycle or sooner when guidance changes.
Kefiw provides educational care-planning tools and guides. This playbook helps families organize decisions, estimate needs, prepare questions, and identify next steps. It does not replace medical, legal, tax, financial, insurance, Medicare, Medicaid, or emergency guidance. For urgent medical concerns or immediate danger, call emergency services.