HOSPITAL DISCHARGES, DEMYSTIFIED
Discharge planning is one of the most misunderstood parts of a hospital stay. For families, it often feels like a sudden, jarring shift: one day you're waiting for an update, and the next you're told it’s time to go. But behind the scenes, there are systems, data, people, and pressure. To demystify the process, we spoke with Alicia Tennenbaum, LCSW, a seasoned healthcare leader and consultant and former director of social work, discharge planning, and care transitions at Mount Sinai in New York City. What followed was a frank and eye-opening conversation about what really happens between the diagnosis and the doorway.
This interview is part of Wellworth’s Behind the Curtain Series, which takes readers beyond the surface of healthcare to explore what really drives outcomes, decisions, and care experiences.
Q: What drew you to hospital-based social work?
Alicia Tennenbaum: I started out studying psychology and sociology, and eventually earned my master’s in social work at NYU. My first internship was at a homeless shelter, which taught me a lot but also made me realize I wanted a more structured environment. That led me to hospital-based social work, where I found an intense, high-stakes space that demanded both clinical and practical problem-solving. I ended up staying at Mount Sinai for over two decades, eventually leading the social work and care transitions teams across multiple campuses.
Q: How has the role of social workers in hospitals evolved over the years?
Alicia: The core tension has always been between clinical work — helping patients cope emotionally and psychologically — and logistical work like discharge planning. They’re deeply connected, though. You can’t help someone plan their next step if they’re still emotionally in crisis. What’s changed is technology. Electronic referrals and tools have streamlined a lot of the paperwork, which gives social workers more time to actually sit with patients and do meaningful assessment and care planning.
Q: What was your day-to-day like running social work and care transitions?
Alicia: It was like being an air traffic controller. Every day was about solving puzzles in real time — reviewing patient flow, managing staff, analyzing data, dealing with unexpected issues, and constantly communicating with external providers. Hospitals live and die by throughput. If we can’t safely move someone out, we can’t take the next patient in.
Q: Most people assume once a doctor discharges a patient, they go home recovered. What really happens behind the scenes?
Alicia: That’s the biggest misconception. People think hospitals are places you go to heal. In reality, you’re diagnosed and stabilized there, and then you heal at home. Recovery happens after discharge. From the moment a patient enters the ER, we're thinking: Do they need to be admitted? How soon can they safely go home? Hospitals are tracking length of stay from day one. It may feel abrupt, but it's about safety, resource management, and ultimately getting people back to the environments where they’ll recover best.
Q: Can you share a case that really stuck with you?
Alicia: There are many, but one from early COVID stays with me. A father and son came in; the father was the sole caregiver, and the son had a significant developmental disability. We knew the father wouldn’t survive. The son wasn’t even our patient yet, but I had to act quickly. With no physical access to the room, a translator on a screen, and only minutes at a time, we gathered information, made legal arrangements, and found the son a safe placement. It took six months to finalize, including court guardianship. That was social work in its rawest form: fast thinking, limited resources, real lives.
Q: What are the biggest obstacles in getting patients discharged safely?
Alicia: A major challenge is that families don’t realize how much of the burden falls on them after discharge. Even basic things like wound care or catheter management often fall to relatives. Many assume the hospital keeps patients until they‘re “fine.” That’s not the case. Families have to be involved, educated, and available — but too often, they don't know how critical their role really is.
Q: Are there unique challenges when working with high-net-worth individuals?
Alicia: The core issues are surprisingly universal. But having resources removes some barriers and creates others. These families can afford better support but still face complex decisions. Who makes medical choices? Are family members aligned? Planning ahead is key, especially when it comes to finding the right providers, advocates, or home care setups. And even with wealth, the system still requires navigating — and it’s easier when you can enlist an advocate who knows it well.
Q: What do patients and families misunderstand most about discharge?
Alicia: That their role is passive. It’s not. Families are expected to learn how to do things like injections or dressing changes. They’re expected to be present, ask questions, advocate, and act. The hospital doesn't send you home when you’re fully healed. It sends you home when you’re safe to recover elsewhere.
Q: What advice do you have for families during discharge planning?
Alicia: Be available. Be proactive. Don’t wait until the discharge meeting to raise concerns. Ask early. Speak up. Write things down. Bring another set of eyes and ears if you can. And if you can afford professional help, get someone who knows the system to advocate for you. That can make all the difference.
Hospital discharge is not an ending. It’s the handoff to what might be the most vulnerable phase of someone’s recovery. What Alicia Tennenbaum, LCSW makes clear is that discharge planning is never just paperwork — it’s a complex, emotional, and high-stakes process. The more families understand their role, the better the outcomes. And in a system stretched for time and resources, that understanding is not just helpful — it’s essential.