Working With Your Care Team¶
During a hospitalization or a health crisis, you will likely meet several professionals at once: a social worker, a case manager, a discharge planner, sometimes a patient representative. Titles and duties for these roles vary by hospital, agency, and state, and no single source defines them the same way everywhere. Ask each person directly what their title means for your situation.
Who is on the care team¶
Your care team can include family, friends, doctors, and social workers, along with anyone else you trust and choose to add.1 Hospital care teams typically include primary and specialty doctors, local agencies, social workers, and mental health counselors, alongside informal supports of family, friends, and community members.1
If you cannot get medical information you need as a caregiver, ask by name for the medical provider's or facility's social worker, patient representative, or privacy officer. This guide does not separately define "case manager" or "discharge planner" duties; treat those titles as local variants of the same care-coordination role until the facility tells you otherwise.
Your rights under caregiver-designation (CARE Act) law¶
More than 40 states have adopted a caregiver-designation law based on the CARE Act, a model bill written by AARP. There is no federal CARE Act. New York's version requires hospitals to:
- Give the patient or their legal guardian at least one chance to identify at least one caregiver before discharge or transfer1
- Attempt to notify that caregiver before a transfer to another facility, or before the patient returns home1
- Consult with the named caregiver and patient about post-discharge needs at home, and offer the caregiver education in the post-discharge tasks they will be expected to do, taking the caregiver's own capabilities and limits into account1
- Name the caregiver, the recommended post-discharge care, and community-resource contact information in the written discharge plan1
This is New York State's implementation. Notice timing, exact duties, and enforcement vary by state. Confirm your own state's CARE Act provisions before relying on this list, especially if you are a rural caregiver working with a facility that may be less familiar with the law.
You have the right to be involved in hospital discharge planning, be trained in necessary care, learn about the person's condition, and ask for help and set limits.1
Partnership tactics¶
- Pick one doctor or point person on the team you can communicate with comfortably1
- Prepare specific questions and note the key changes in the condition before each conversation1
- Keep a current medication list (drug name, strength, frequency, and refill timing) and bring it to every conversation1
- Ask plainly for what you need: information, referrals, refills, or new prescriptions1
- Ask the team to define terms you don't understand, and ask about the pros and cons of each treatment option before agreeing to it1
If you hit a wall on information sharing¶
Healthcare professionals can share medical information with caregivers directly involved in a person's care if the patient has a reasonable understanding of the situation and opportunity to object.1 HIPAA does not require written consent for sharing with caregivers, though some facilities ask for a signature anyway.1 If you still cannot get the information you need, ask for the facility's social worker, patient representative, or privacy officer by name.1
If you're in a rural area with few providers¶
This source does not address rural provider shortages directly. If a hospital or agency has no dedicated case manager or social worker on staff, ask who currently holds discharge-planning responsibility, and ask for the community-resource contact information that a compliant discharge plan is required to include1.
This page documents caregiver rights and communication practices from one state's caregiver guide. It does not measure whether any specific care-coordination program improves outcomes.