When Does Discharge Planning Start?
Discharge planning begins on the day your loved one is admitted, not when you're ready to leave. Federal regulations require it. The goal is to prepare for your loved one's eventual transition out of the facility—home, assisted living, another facility, or hospice.
This doesn't mean you need to rush discharge. Rather, the facility is continuously assessing your loved one's rehabilitation progress and considering whether they could be discharged to a less intensive setting. If your loved one stops needing skilled nursing (wound care, IV medications, physical therapy), the facility will begin discharge planning in earnest.
You should be proactive about discharge planning even before the facility raises it. Ask at care conferences: "What would your loved one need to do to be safely discharged home?" or "What's the plan if they plateau on therapy?" Understanding the path forward gives you time to prepare.
Who's on the Discharge Planning Team?
The discharge planning team typically includes: the patient (if able), family members, the physician, the case manager or social worker, nursing staff, physical therapy, occupational therapy, speech therapy (if applicable), and sometimes a dietitian or psychiatrist.
This is called an interdisciplinary team. They meet regularly (usually monthly or more often if discharge is imminent) to assess your loved one's progress and plan next steps.
You should attend these meetings. You know your loved one's home, family situation, and preferences. Your input is essential to realistic planning. If you can't attend in person, ask to join by phone or video.
What Are the Main Discharge Options?
The options are:
Home: Return to your loved one's own home, with family caregiving and/or home health services.
Assisted living: A less intensive facility that provides help with daily activities but not skilled nursing care.
Another nursing facility: Transfer to another SNF, often for a different level of care or for access to specific services.
Hospice: If your loved one is approaching end of life, transition to hospice care (at home, in a facility, or in a dedicated hospice setting).
Therapy should clarify which options are realistic given your loved one's medical and functional status. A person still recovering from a stroke might return home with outpatient therapy. A person with advanced dementia might be better suited to assisted living. Someone at end of life is appropriate for hospice.
What Does "Safe to Discharge" Actually Mean?
Safe discharge means your loved one can function outside the nursing home setting with whatever support is arranged. This is not the same as "fully recovered" or "back to baseline."
For home discharge, safety means: your loved one can transfer in and out of bed (with or without equipment), take medications safely (with or without help), manage bathroom needs (with or without equipment), and manage medical care like wound changes or IV medications if those are still needed.
It also means the home is suitable. Are stairs a problem? Is the bathroom accessible? Are caregivers available and trained? Are necessary equipment and medications in place?
The discharge planning team will identify what's needed to make discharge safe. This might be grab bars, a hospital bed, a commode, home health nursing, physical therapy, or a family member taking time off work.
If your loved one cannot safely go home, other options are more appropriate.
What's a NOMNC Notice and What Does It Mean?
NOMNC stands for "Notice of Medicare Non-Coverage." It's a formal notice that Medicare will stop covering your loved one's stay in the nursing facility.
Medicare covers skilled nursing care when your loved one needs it. Once their condition stabilizes and they no longer need daily skilled care—physical therapy, wound care, IV medications—Medicare coverage ends.
The facility must give you a NOMNC notice at least 2 days (in some cases, more) before they stop covering the stay. This is your signal that discharge planning is becoming urgent.
After the NOMNC, you have two options: arrange discharge (with payment plan if needed) or appeal Medicare's decision to stop coverage. Many families appeal because they believe their loved one still needs skilled care. The appeals process requires physician documentation and takes time.
Can You Appeal a Discharge Decision?
Yes. If you disagree that your loved one is ready to be discharged, you can appeal. Document your concerns: your loved one still needs wound care, they're not safe at home alone, therapy goals haven't been met, etc.
Request a Utilization Review appeal. This goes to a physician (not affiliated with the facility) who reviews your loved one's chart and your appeal. You have the right to speak with the reviewing physician.
While the appeal is pending, the facility must continue covering care. If the appeal is upheld, coverage continues and discharge is delayed. If the appeal is denied, you proceed with discharge.
Many families win appeals. Documentation (therapy notes showing continued progress, physician notes supporting continued skilled care) strengthens your case.
Ask your facility's case manager or social worker how to file an appeal. They should guide you through the process.
What Needs to Happen Before Discharge Home?
A safe discharge home requires planning:
Equipment: Assess what your loved one needs. A walker? A shower chair? A commode? A hospital bed? Grab bars? Ramps for stairs? The occupational therapist will identify these. Some can be rented or purchased; some the facility or insurance may provide.
Home accessibility: Can your loved one physically function in the home? Are bathrooms accessible? Are bedrooms on a manageable floor? If not, adaptations may be needed.
Medication management: Ensure medications are set up clearly. Consider a pill organizer or pharmacy-delivered blister packs. Have a written list of all medications.
Caregiver training: If your loved one needs help, family members must be trained. This might include wound care, medication administration, transfers, or dementia care. Therapy and nursing should provide training before discharge.
Home health arrangement: If your loved one needs ongoing skilled care (wound changes, IV medications, therapy), arrange home health in advance. This typically starts within a day or two of discharge.
Medical follow-up: Schedule physician appointments for after discharge. Your loved one should see their doctor within 1–2 weeks.
Transportation: Plan how your loved one will get home (ambulance, family car with adaptation) and to medical appointments.
The discharge team should guide all of this. Ask for a written discharge plan.
Key Questions to Ask at Discharge Planning Meetings
Come prepared with these questions:
What is the goal? Is the plan for home discharge, assisted living, another facility, or hospice? By what date?
What needs to happen? What therapy goals remain? What equipment is needed? What training do family members need?
What does safe discharge require? What medical, functional, and home modifications are needed?
What happens after discharge? Who follows up? When is the first physician appointment? Will home health be involved?
What if we disagree? If you think discharge is too early, how do we appeal?
What if things go wrong? If your loved one isn't doing well after discharge, can they return to the facility? What should prompt readmission?
Who's the point person? Who do you call with questions between now and discharge?
Take notes. Request a written discharge plan. This is your roadmap.