Your Care After Discharge From the Hospital (The James)

Your Care After Discharge From the Hospital (The James)


Planning for your discharge starts before you are admitted to the hospital. The first several weeks after you leave the hospital is an important time for your recovery. The goal of discharge planning is to make sure you have a good plan in place to meet your needs and to prevent an unexpected return to the hospital.

You will need to have a plan in place for your care after discharge, before you come to the hospital for your surgery.


What questions should I ask my health care team about the help I may need after surgery?

Here are some important questions to ask your health care team to help you make your plan:

  • After my surgery, will I be able to go home or will I need to go to a skilled nursing facility (SNF)?
  • If I go home, will I need someone to stay with me all the time? If I need a caregiver, how many days will they need to be with me?
  • Will my caregiver need to be trained on how to care for me? Will that training be given in the hospital before I am discharged?


Discharge From the Hospital

  • During your hospital stay, your health care team will teach you and your caregiver how to take care of your needs after you leave the hospital.
  • Before you leave the hospital, you and your caregiver will be given your discharge instructions. This information will include:
    • Follow-up appointment with your doctor
    • Important phone numbers
    • What to do if you have problems after surgery
    • Directions for how to care for yourself
    • A list of your current medicines and any new prescriptions
    • Information on what you can do to help your recovery
    • Medical equipment and home health care information


What services are available to help with my care after discharge?

Most patients return home after their hospital stay, but at times, but at times, extra care is needed after discharge. Talk with your health care team if you think you need more help after discharge, or do not feel you can manage your care at home.

Coverage for these extra services is different for each insurance plan. Our team of social workers, patient care resource managers and financial counselors can check your insurance plan and help you make arrangements for these services, if needed. These may include:

  • Home Health Care – provides limited services to help you recover at home. The number of visits each week and the amount of time for each visit is based on your care needs.
    • Insurance plans do not provide coverage for 24 hour assistance in the home.
    • Nursing and aide services can be arranged for longer periods of time, but this cost is not covered by insurance. You would have to pay for these services from an agency of your choice.
    • If you need continuous care for a tracheostomy or feeding tube and plan to go home at discharge, you will need to have someone help you with this care.
  • Skilled Nursing Facility (SNF) – offers short-term and long-term care for those who need rehabilitation or have an illness that is too difficult to be managed at home. This care is provided 24 hours a day, 7 days a week.
    • Check with your insurance company to find out what your plan covers for SNF care. It may be helpful to visit the SNFs in your area, so that you are prepared to share your choices with the health care team when you come to the hospital.
  • Hospice Care – this is not a place, it is a special kind of care that provides comfort and symptom management to those with a life limiting illness. The hospice team supports the family and teaches them to be the primary caregiver. Hospice care can be given in a home, skilled nursing facility or assisted living facility.
  • Community Resources – these services may include help with financial or insurance issues and transportation or housing problems.


Important Phone Numbers

The James Cancer Hospital

  • Patient Care Resource Manager (PCRM) and Social Work Office (614) 366-5119

The Ohio State University Wexner Medical Center East Hospital

  • Patient Care Resource Manager (PCRM) (614) 257-3257
  • Social Work Office (614) 293-8427

Wexner Medical Center

  • Case Management Office (614) 293-8141
  • Social Work (614) 257-3257

Financial Services

  • The James Cancer Hospital and Wexner Medical Center (614) 293-4241
  • The Ohio State University Wexner Medical Center East Hospital (614) 257-3933



© February 25, 2019. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.

This handout is for informational purposes only. Talk with your doctor or health care team if you have any questions about your care.