The call can come fast. Dad’s doing better, and he’s going home Friday. You’re relieved, and then you wonder what home needs to look like. This checklist takes it in order: before he leaves, before he arrives, and the first two weeks.
What should we ask before Dad leaves the hospital?
Medicare says you and your caregiver are important members of the discharge planning team, and it publishes a checklist for you. Talk these items through with the discharge planner, social worker, or nurse, and write the answers down.
- Names and phone numbers of the people to call with questions after you get home.
- Which complications to watch for, and what to do if you see one.
- A full medication list: prescriptions, over-the-counter drugs, vitamins, and herbal supplements. Note what changed during the stay, which ones to keep taking, and at what dose.
- Where your parent will get care after discharge, and whether there are options like home health care.
- Whether your parent will need equipment, like a walker, whether Medicare covers it, and who will arrange delivery.
- Whether your parent is ready to bathe, dress, use the bathroom, climb stairs, cook, shop, clean, pay bills, pick up prescriptions, and get to appointments. Circle the ones they’ll need help with.
- A hands-on lesson for any task that takes special skill, like changing a bandage or giving a shot. Practice it yourself before you leave.
- Written discharge instructions you can read and understand, plus a summary of your parent’s current health. Bring both, and the medication list, to every follow-up appointment.
Ask whether your parent was admitted or kept under observation
Ask the doctor or hospital staff each day whether your parent is an inpatient or an outpatient under observation. Medicare says someone can stay overnight in a regular hospital bed and still be an outpatient. If your parent is under observation for more than 24 hours, the hospital must give you a written notice called the MOON.
Status matters if your parent may need a skilled nursing facility next. Original Medicare usually covers that care only after a medically necessary inpatient stay of at least three days in a row. Time under observation or in the emergency room before admission doesn’t count. Some Medicare Advantage plans and some doctor groups can waive the three-day rule, so ask.
What should be ready at home before the first night?
Medicare’s checklist tells caregivers to pick up prescriptions and run errands, like buying food for a special diet, before discharge day. That saves extra trips once your parent is home.
Then walk through the house with falls in mind. More than one in four adults 65 and older falls each year, according to the CDC. Its home safety checklist suggests these fixes:
- Put a lamp close to the bed, where it’s easy to reach.
- Add a nightlight along the path from the bed to the bathroom.
- Lay a non-slip mat or strips on the floor of the tub or shower.
- Install grab bars next to and inside the tub, and next to the toilet.
- Remove throw rugs, or secure them with double-sided tape or a non-slip backing.
- Keep papers, shoes, and other things off the floor and stairs, coil or tape cords next to the wall, and move furniture out of walking paths.
- Keep everyday items on lower shelves, about waist high. If a step stool is a must, use a sturdy one with a bar to hold on to, never a chair.
- Check that stairs have working lights at the top and bottom and sturdy handrails on both sides.
What does the first week at home look like?
Check each medicine against the updated list from the hospital, not the old bottles in the cabinet. If anything doesn’t match, call the doctor or pharmacist before giving it. Put the follow-up appointments on a calendar, and plan rides to those appointments now, not the morning of. Keep the list of complications and the hospital’s phone numbers by the phone.
Watch how your parent moves when getting out of bed at night, walking to the bathroom, and stepping into the tub or shower. The CDC suggests asking the doctor or pharmacist to review medicines that might cause dizziness or sleepiness. If the instructions name a special diet, plan meals around it.
What should we check in the second week?
By week two, go back to the daily activities you circled at the hospital. Which can your parent do alone now, which need a hand, and which still aren’t safe?
Check on yourself as well. Medicare’s checklist asks caregivers to think about which tasks they need help with and whether they need any training. If you’ve been sleeping on the couch to hear Mom at night, say so to her doctor and the family.
Does Medicare pay for help at home after a hospital stay?
Medicare pays for home health care, which is part-time skilled care like nursing and therapy, when your parent qualifies. A doctor or other provider must have a face-to-face visit with them (which can be by telehealth) and order the care, and they must be homebound. That means leaving home isn’t recommended, or takes a lot of effort and help. With Original Medicare, you pay nothing for covered home health services, though you’ll usually pay 20% of the approved amount for medical equipment like a walker after the Part B deductible. Our guide to home care vs. home health in Oregon explains how the two differ.
Medicare doesn’t pay for 24-hour care at home, meal delivery, or help with daily activities when that’s the only care your parent needs. That’s the gap many families fill with in-home care.
For free, one-on-one Medicare help, Oregon’s SHIBA program has trained counselors at 1-800-722-4134. For other ways to pay, including Medicaid, see our guide to paying for in-home care in Oregon. The Aging and Disability Resource Connection (ADRC) at 1-855-673-2372 can help you find long-term care services.
What if the discharge feels too soon?
If your parent has Medicare, was admitted as an inpatient, and you think they’re being sent home too early, you can ask for a fast appeal. The hospital staff should give you a notice called the Important Message from Medicare, which explains your appeal rights. If you don’t get it, ask for it. An independent reviewer under contract with Medicare then decides whether covered care should continue. Call 1-800-MEDICARE (1-800-633-4227) for the reviewer’s number. If the hospital changed your parent from inpatient to outpatient with observation, that’s a different case. Medicare has a separate appeal for it, and the hospital should give a Medicare Change of Status Notice before discharge. Ask the hospital, or call 1-800-MEDICARE, how to file.
How Pasha can help
Pasha Health offers post-hospital recovery care for the weeks after discharge. One assigned caregiver can help with personal care, meals, around-the-home tasks, and rides to follow-up visits, working from a written care plan. When the plan calls for it, a caregiver can also do nurse-delegated tasks under a doctor’s orders. If nights are the hard part, we offer overnight and 24-hour care too, and we accept Medicaid.
If your parent is coming home soon, take the two-minute assessment or schedule a 15-minute call. Having the discharge papers and the medication list nearby can make the call easier.
Questions families ask
Does Medicare pay for a caregiver after a hospital stay?
Not for everyday care on its own. Medicare covers part-time skilled home health care for people who qualify, and that can include some aide help alongside the skilled care. It doesn’t cover 24-hour care, or help with daily activities when that’s the only care needed.
Dad stayed overnight. Was he admitted?
Not necessarily. Medicare says you can spend the night in a regular hospital bed and still be an outpatient under observation. Ask the doctor or hospital staff. It matters if he might need a skilled nursing facility, because observation time doesn’t count toward Original Medicare’s three-day inpatient requirement.
What should we have ready for the first night home?
Filled prescriptions, the updated medication list, food that fits any diet instructions, a lamp within reach of the bed, a nightlight on the way to the bathroom, and a clear path with no loose rugs.
Can a home caregiver help with medical tasks?
In Oregon, it depends on the agency’s state license class and, for nursing tasks, on what a registered nurse delegates under a doctor’s orders. At Pasha Health, caregivers can do nurse-delegated tasks under a doctor’s orders as part of the written care plan. Ask any agency you’re considering exactly which tasks its caregivers may do.