Medical Social Services in Minnesota

Discharge Planning

Discharge planning is essential to assure continuity of care following hospitalization. The physician and primary nurse begin the discharge planning process during admission to the hospital. The following guidelines are used at Mayo Clinic for discharge planning:

• Patient and family actively participate in reviewing options presented by members of the health care team.
• All discharge planning is coordinated with the medical treatment plan of care.
• The physician is responsible for determining the medical treatment plan for dismissal.
• Other members of the health care team are responsible for discharge planning that relates to their professional expertise.

When the discharge plan is expected to be complex, a social worker is often involved. The social worker will meet with the patient and family to assess needs and help determine the resources available. Factors in the assessment include:

• Physical and emotional needs
• How much assistance is available from family and friends
• What resources in the community can help with care
• Financial resources

Following assessment, the social worker will advise about possible options and recommend the most appropriate plan. The patient and family will decide on which plan to follow. When a plan is set, the social worker will coordinate the arrangements.

Hospital Utilization Review Department

The Hospital Utilization Review Department frequently reviews the length of hospitalization and determines whether continued hospitalization in an acute care setting is necessary. If it is determined that acute care is no longer necessary, insurance may no longer cover the costs of hospitalization. This is another reason discharge planning is essential.

Please contact the Medical Social Services office at (507) 284-2131, for more discharge planning information.