The transition from hospital discharge to hospice involves a destination, records, equipment, medications, transportation and clear handoffs. A family checklist can help everyone confirm the next step before the patient leaves the hospital.
Start the conversation before discharge
Tell the hospitalist, bedside nurse, case manager or social worker that the family wants information about hospice. The hospital can send records and coordinate with a hospice agency. A family can also contact a hospice directly or review the referral pathway to ask what information is needed. This is an information-gathering step.
Ask where the patient will go after discharge, who will be there, what symptoms need attention and what equipment is needed. Provide the complete destination address and best contact numbers. If the patient will go to assisted living or skilled nursing, include the facility contact.
What the hospice reviews
The hospice reviews the diagnosis, recent hospital course, functional changes, symptoms, medications and goals. Eligibility is individualized; it is not decided from the discharge diagnosis alone. A physician must certify eligibility under the hospice benefit and the hospice’s reviewing physician participates as required.
The family should receive a clear explanation of the proposed plan, including services, visit expectations, coverage questions and the number for on-call support. Ask for plain language if any part of the paperwork is confusing.
Plan the first hours at home
Discharge planning should address medications, equipment, supplies, transportation, oxygen if ordered and who will be present. Confirm whether equipment will arrive before the patient or shortly afterward and what to do in the meantime. Keep the discharge summary and medication list available for the hospice nurse.
Set up a comfortable resting area with a clear path to the bathroom or bedside equipment. Have water or preferred drinks available if safe and desired, phone chargers nearby and the hospice number where everyone can find it. Do not alter medications without instructions from the treating clinicians.
If plans change
A discharge can be delayed or a patient may return to the hospital. Notify the hospice and hospital team promptly so they can coordinate. Choosing hospice does not erase a patient’s right to ask questions or reconsider. The hospice should explain how revocation, a change in setting or a return to disease-directed treatment would work.
Hospice offers 24/7 on-call support after enrollment for questions and response planning. That service is not a guarantee of continuous bedside nursing. For urgent symptom changes related to the terminal illness, call the hospice team first unless the patient’s care plan directs otherwise. Follow the patient’s emergency plan when emergency services are needed.
A short transition checklist
Confirm the hospice contact and first visit; destination and caregiver; medication list; equipment delivery; physician communication; advance-care documents; and transportation. Ask who will handle questions overnight. If the discharge is occurring on a weekend or holiday, make the plan especially specific.
Families can ask a hospice to explain its local process. Good coordination reduces surprises and gives caregivers a steadier start.
Practical next steps for your family
A referral partner can make the handoff easier by naming the patient’s goals in the discharge summary and confirming the hospice contact. Families should ask whether prescriptions are ready, whether durable equipment has been ordered and whether a nurse will call before arrival.
If the patient cannot safely return home, ask about other settings and whether hospice can coordinate there. The right setting depends on clinical needs, caregiver availability, patient preference and facility policies. A hospice cannot guarantee a particular placement, but it can help the family understand the conversation to have with the hospital and facility.
After discharge, call the hospice with any change that concerns you rather than waiting for the next routine visit. Describe what you see, what the patient says and when the change began. The on-call clinician can provide guidance and determine the next step.
Before leaving the hospital, ask who is responsible for each handoff: the hospital for records, the hospice for its admission visit, the physician for orders and the family for a reliable contact and safe setting. Write those names down. Review the family evaluation guide for the earlier conversation and use the First 48 Hours resource for what follows enrollment.
The first night may feel unfamiliar even when the plan is sound. Keep the patient’s preferences visible, avoid rushing through care and call for guidance when a symptom or instruction is unclear. A calm, documented handoff gives the hospice team a better chance to respond appropriately.