Your Parent Is Discharged Tomorrow: A 48 Hour Plan

Read this first

Someone just told you your mother or father is going home tomorrow. You have no bed, no plan and no time off work. This page is a list of what to do, in the order to do it. Work down it. Skip nothing in the first section, because most of it can only be done while you are still inside the hospital.

Keep one notebook or one note on your phone. Write every name and direct number you are given. You will need them at 9pm when nobody answers the main line.

Hours 0 to 2: while you are still in the building

Find the discharge planner

Every hospital has a discharge planner or case manager. Ask the nurse for that person by name and ask for their direct number. Medicare requires hospitals to screen inpatients and plan the discharge for those who need it. If nobody has done a discharge planning evaluation, ask for one out loud.

Ask these questions before you leave the room

Is my parent an inpatient, or on observation status? This matters. Observation is billed as outpatient, and observation days do not count toward the three inpatient days Medicare requires before it will pay for a skilled nursing facility stay.
What exactly happened, in one sentence I can repeat? You will repeat it to the pharmacist, the doctor’s office and the aide.
What can she do by herself, and what can she not do? Walk. Stand from a chair. Get to the toilet. Wash. Dress. Cook. Be alone for four hours. Ask about each one.
What are the warning signs, and who do I call at 2am? Get a number that is answered at night.
What equipment is coming, who ordered it, and when does it arrive?
Was home health ordered? Which agency? When is the first visit?
Which follow-up appointments are booked, and which do I have to book?
Is there anything I need to be taught before we leave? Wound care, injections, a feeding tube, oxygen. Ask them to show you, then do it yourself while they watch.

Ask for these papers, on paper

The written discharge summary and instructions
The complete medication list, with the dose and the time for each one
Prescriptions, sent to a pharmacy you have already checked is open
Diet instructions, if there are any
The direct numbers: discharge planner, the ward, the doctor’s office, the home health agency

If tomorrow feels too soon

You have an appeal right. Within two days of admission and again before discharge, Medicare patients get a notice called “An Important Message from Medicare about Your Rights”. If you think the discharge is unsafe, follow the directions on that notice and call the Quality Improvement Organization no later than the day of the planned discharge. For Virginia, that organization is Commence Health, on 1-888-396-4646. If you appeal in time, your parent can stay while the decision is made, and you do not pay for those days beyond the usual deductible and coinsurance. A decision normally comes within about a day.

Use this when the discharge is unsafe, and use it early in the day. It is not a way to buy a week.

Hours 2 to 6: the medicines

Do this step slowly. It is the easiest one to get wrong and the hardest to undo.

Bring every bottle from home into one bag. Everything. Pills from other doctors, inhalers, eye drops, insulin, vitamins, herbal remedies, anything sent from family abroad.
Put the hospital list next to the bag. Match them one by one.
Ask the nurse or pharmacist about every difference. Is this one stopped for good, or paused. Is this a new name for the same drug. Is the dose changed.
Ask specifically about blood thinners, insulin, blood pressure medicines and pain medicines. These are the ones that cause the emergency room visit.
Fill the prescriptions before you drive home. Call the pharmacy and confirm they have the drug in stock. If a medicine needs prior authorization from the health plan, you want to know that today.
Write one final list and tape it to the refrigerator. Morning, midday, evening, night. Put the old bottles in a separate bag and take them out of the kitchen so nobody takes them by mistake.

Hours 2 to 6: equipment, and who pays

Ask the discharge planner exactly which items are ordered and which supplier is delivering them. Common items are a walker, a wheelchair, a hospital bed, a bedside commode, oxygen, or a cushion.

Medicare Part B covers durable medical equipment when a doctor orders it for use in the home. After the Part B deductible, the usual share is 20 percent of the Medicare approved amount, as long as the supplier is enrolled in Medicare and accepts assignment. Some items are rented rather than bought. If your parent has Medicaid or a Medicare Advantage plan, the rules differ, so ask.

Two things to check before you accept a delivery slot:

Ask what you will owe. Ask the supplier, in the same call, whether they accept assignment. That question changes the price.
Ask what is not covered. Bathroom safety items such as grab bars and shower seats are often paid for by the family. Ask item by item rather than assuming.

If a hospital bed is coming, decide now which room it goes in and clear that room today. A bed cannot be delivered into a room full of furniture.

Hours 6 to 12: get the house ready

Do the safety work before the person arrives, because you will not have hands free afterwards.

Clear the path from the bed to the bathroom. Lift the rugs. Move the low table. Tape down any cord that crosses the floor.
Light that path. A night light in the hallway and one in the bathroom. Falls happen on the way to the toilet in the dark.
Set up the sleeping place on one level. If the bedroom is upstairs and the stairs are now a problem, make a bed downstairs for the first week.
Put a chair with arms in the bathroom and one near the bed. Arms are what a weak person pushes up from.
Phone, water, glasses, tissues and a light switch within arm’s reach of the bed.

Buy or borrow, today: a pill organizer, incontinence pads or briefs if there is any doubt, wipes, a thermometer, a plastic bottle of water that does not tip, soft food that needs no cooking, and a notebook for the log.

Hours 12 to 24: the first night

Assume the first night will be broken. Plan for it rather than hoping.

Decide before dark who is awake and when. If you have a sibling or a cousin, split the night now, in writing. If you are alone, sleep in the same room or the next one with both doors open.
Do a last toilet trip before bed and again if your parent wakes. Many night falls are a rush to the bathroom.
Set the medicine alarms on your phone for the first 72 hours. You will not remember at 4am.
Keep the warning-signs page by the phone with the night number written on it.
Leave a hall light on. A new environment, low light and tiredness are exactly the combination that produces confusion at night.

Call an ambulance rather than waiting until morning for: chest pain, trouble breathing, sudden weakness on one side, face drooping, sudden trouble speaking, a fall with a head injury, a wound that will not stop bleeding, or a person you cannot wake properly.

Hours 24 to 48: day two

Call the primary care doctor and book the follow-up. Aim for within seven days. Say the words “just discharged from hospital” when you call, because that moves the appointment.
Call the health plan. If your parent has Medicaid or Medicare Advantage, ask for the care coordinator by name. Ask what home care benefit exists and what the plan needs from you to start it.
Call the home health agency if one was ordered and confirm the date of the first nursing or therapy visit. If nobody has called you by day two, chase it.
Confirm the equipment arrived and that someone showed you how to work it. If a delivery was missed, call the supplier and the discharge planner.
Start the log. Date, temperature if asked for, what was eaten and drunk, bowel movements, medicines given, how they slept, anything odd. One page a day. It answers half the questions the doctor will ask on day seven.
Look at your own week. Work out which shifts you truly cannot cover and start arranging those now, before you are three nights short of sleep.

What Medicare home health is, and what it is not

This trips up almost every family in the first week. Medicare home health and hourly home care are different things.

Medicare home health pays for part-time or intermittent skilled nursing, physical therapy, occupational therapy, speech therapy, and a home health aide alongside those skilled services. Your parent must be certified as homebound and assessed face to face by a provider.
Medicare does not pay for 24-hour care at home, home meal delivery, homemaker services unrelated to the care plan, or personal care alone when help with daily activities is the only care needed.

So the nurse who comes twice a week to check the wound is home health. The person who comes for four hours in the morning to bathe your father, cook and stay with him is home care. If long-term hourly help is what you need, it is paid for privately, through a Medicaid waiver, through long-term care insurance, or through veterans benefits.

When home care can realistically start

Straight answers, because the timing decides your week.

Medicare home health: usually starts within a day or two of discharge when the hospital has ordered it and an agency has accepted the referral. It is visits, on a schedule, not cover.
Private pay hourly care: normally the fastest to begin. How fast depends on the town, the shift and the language needed. No honest agency will give you a start time before checking who is free.
Medicaid waiver personal care: the slowest. It needs a Long Term Services and Supports screening through your local Department of Social Services, a Medicaid decision, and an authorization from the health plan. Families commonly wait weeks. Start it now even if you bridge the gap another way, because the clock only starts when someone calls.

If the discharge is tomorrow, plan the first week with what you can arrange tomorrow, and run the Medicaid application in parallel.

If you are the only one

Write down the three hours in the week that frighten you most. The Tuesday night shift. The Thursday school run. The 6am. Those are the hours to buy help for first, and they are cheaper to cover than the whole week. Ask about respite care specifically. Ask your parent’s health plan whether respite is part of the benefit.

Talk to a care coordinator

If the discharge is tomorrow, call and tell us what is going on at home. We will tell you what a caregiver can do, what it costs, and what we would need to cover the shift you are worried about. If we cannot cover it, we will tell you quickly rather than leave you waiting.

Call (703) 941-8412, Monday to Friday, 9:00 am to 5:00 pm. We speak English, Amharic, Tigrinya and Spanish. The in-home assessment is free and there is no obligation. Millennium Home Health Care, 4200 Evergreen Lane, Suite 312, Annandale, VA 22003.

Sources

This page is general information, written in August 2026. It does not replace the instructions your parent’s doctor and discharge planner give you. Coverage rules change, so check the Medicare pages above or call the health plan.