Regularly, at hospitals all over the Unites States, patients' relatives are told: "The doctor will need to discharge your relative from the hospital in the next day or two. You'll need to find a place for your relative to live since she clearly can't stay at her home by herself any longer."

A family gets the news on a Friday that the medical team must discharge the patient Monday morning. There's panic and an overwhelming feeling of impending doom.

The situation is extremely unpleasant for the medical team as well.

Gone are the days when discharge decisions were exclusively left to the doctor. Now these types of discharge decisions are routinely made by "hospital discharge planners" who work for the hospital and have their eyes primarily on the hospital's financial bottom line.

Often, their goal is not to decide what's best for the patient or family, but what's most profitable for the hospital, considering how much the hospital will be reimbursed.

Increasingly, hospitals are reimbursed a fixed amount of money based on the admitting diagnosis (congestive heart failure, fractured hip, etc.). The longer the patient stays in the hospital, the less money the hospital makes.

Announcement of a pending discharge can leave patients and their families wondering how they can do this.

What are the options? How much will it cost? What if the hospitalized relative doesn't want to go? How can I bring them home to my house?

A recent issue of the medical journal JAMA described a couple in their late 70's who had survived a car crash. The husband was left in a coma and needed to go to a skilled nursing home. The wife broke her ankle.

She was unable to walk. Doctors felt she needed to spend weeks in a rehabilitation hospital receiving physical therapy. She wanted to go home, but it turned out she lived in a house with stairs to the bedrooms. Her children also lived in homes with staircases. She was unable to navigate stairs, prepare her meals, or even shower without assistance.

Her family had no idea of the placement options available to her or the benefits of each option.

The hospital social worker was able to offer advice on where she could go on Monday after the hospital discharged her, but it wasn't the social worker's job to offer assistance on long-term planning.

The social worker explained that federal Medicare offers limited coverage for rehabilitation services (called post acute care), but that coverage quickly runs out. Forty-five percent of Medicare patients leave the hospital and go to a rehabilitation facility.

Medicare does not offer coverage for long-term care like that required by this couple.

For the couple in this article, there were only two options – pay for care themselves (either directly or through the early purchase of extremely expensive long-term health insurance) or spend down to the point of poverty and then state Medi-Cal would pay for nursing home care.

But they were warned: The nursing home may not be the facility of their choice or even one near relatives.

Most physicians are not experts on insurance coverage, rehabilitation, or nursing home care. Given the rapidly aging population, however, it is high time doctors learn the basics so we can advocate for our patients.

This is important as insurance companies, hospitals and nursing homes try to skim off patients who have money and can pay their own way, and dump those who can't afford the care.

Doctors need to make sure patients and their families engage in a process of shared decision-making in which the facts are presented in a clear, understandable, honest and transparent fashion. It is the doctor who has the best ability to advocate on the patient's behalf.

The health care team knows that the more times the person is transferred from place to place, the more difficult it is provide good medical care and the more opportunities there are for mistakes.

Discharge is stressful for patient and family, and where a person ends up residing can have important implications on both the length of their life and the quality of that life.

Research shows that the most dangerous time in a person's medical care is during transitions from place to place. The goal is to minimize such transfers and maximize quality of life.

This couple were given a list of nursing homes that had open beds rather than a list of recommendations as to where they would receive the best care.

When the family voiced frustration, the doctor suggested they contact a new breed of health professional called a "care manager." These experts can have a variety of backgrounds, although many seem to be social workers or nurses.

Families must pay them directly at rates of about $80 an hour, but they are experts at helping to determine what is in the patient's best interest.

No matter what is done, there are some key questions to ask the doctor, social worker or care manager:

• What are the goals of care that we should hope for?

• What placement options are available?

• How well will each option achieve the desired goal?

• Are there risks associated with any of the options?

• Who will provide the medical care to my relative?

• How long will they stay at the facility?

• What are the costs and will insurance cover any of them?

Once you find a facility that looks good, the next step is to understand its staffing, philosophy and user friendliness. Questions to ask might include:

• How far away is it, and will family and friends be inclined to visit?

• Is there a religious or other philosophy that is acceptable?

• Are there rules that will keep the patient from doing things he values?

• What is known about the institution's track record with quality of care?

• Will my hospital doctor talk directly to their doctor to minimize confusion at the time of transfer?

The couple from the motor vehicle accident were rejected by several nursing homes. It took many calls, and in the end they needed to go to separate facilities, meaning that at the end of their lives they couldn't be together.

In many other developed countries there is social insurance that provides for long-term care.

The best coverage is provided by Japan and Germany, but the Scandinavian countries, the United Kingdom, France and the Netherlands all provide publicly funded long-term care.

In the Untied States, we can't even agree to have government pay for basic health care. In our current anti-government environment, it would be unthinkable to suggest government provide long-term care to protect our elderly. Certainly, as a society we can do much better than we are currently doing for our senior citizens.

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Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Reach him at drwilkes@sacbee.com.

• Read more articles by Dr. Michael Wilkes