Discharged From a Dayton Hospital: A Family Checklist for the First 72 Hours

Hour one: confirm the admission status

Ask the nurse or case manager one question before anything else: was my parent formally admitted as an inpatient, and on what date? Medicare pays for a skilled nursing stay only after three inpatient days. Time spent under observation, even in a regular hospital bed, does not count. If the answer is observation, ask whether the doctor considered admission, and plan on Medicare Advantage or private funds for any rehab stay.

Day one: get the recommendations in writing

Physical and occupational therapists will usually evaluate your parent before discharge. Ask for their written recommendation: home with home health, home with outpatient therapy, short-term rehab in a nursing home, or assisted living. Those notes drive what Medicare and any receiving facility will accept, so read them and correct anything that misstates how your parent lived before the hospital stay.

Day two: choose the next place, not just the next opening

Hospitals give families a list of nursing homes with open beds and often push to fill the first one. You have the right to choose any facility with a bed that accepts your parent's coverage. Here is how many CMS-certified nursing homes sit within five straight-line miles of each hospital in our area, and how many of those hold four or five CMS stars:

Compare short-stay quality, rehospitalization rates and weekend therapy, and favor the home closest to the relative who will visit most.

Day three: line up home support

If your parent is going home, ask the hospital to order skilled home health and confirm which agency will make the first visit and when. Arrange the hours between visits: family, a non-medical agency, home-delivered meals. Fill new prescriptions before discharge and throw out discontinued ones. Book the follow-up doctor's appointment for within two weeks.

For a parent 60 or older who may qualify for Medicaid, call the Area Agency on Aging, PSA 2 at 1-800-258-7277 about PASSPORT; a hospital referral can speed the assessment.

What to pack and what to ask for at the rehab facility

Bring clothes your parent can put on with therapy in mind: elastic waists, non-slip shoes, a sweater for cool therapy rooms. Bring glasses, hearing aids with spare batteries, dentures and a labeled phone charger. Ask on the first day for the name of the social worker or case manager, the therapy schedule and the date of the first care plan meeting, which usually happens within a week or two.

At that meeting ask three things: what goals must be met for a safe discharge home, how progress is measured, and what the backup plan is if goals are not met by the time Medicare coverage ends. Ask how many hours of therapy a day your parent is receiving and whether therapy happens on weekends. If your parent is not improving, ask why, and whether a change of approach or a medical review is needed.

Visit at different times, including an evening, and watch how quickly call lights are answered. If something worries you, raise it with the charge nurse first and the administrator next; the Region 2 ombudsman (1-800-395-8267) also helps residents of rehab units.

The one thing to do tonight

If a parent is in the hospital right now, do one thing tonight: write down what daily life looked like before this admission. Could they walk to the mailbox, shower alone, manage their pills, drive? Bring that page to the hospital tomorrow. Therapists and case managers make recommendations based partly on what they are told about the prior level of function, and families are often the only people who know it. That single page can change the discharge plan and the coverage that follows.

If you disagree with the discharge

Medicare patients receive a notice called the Important Message from Medicare, which explains how to appeal a discharge to the Quality Improvement Organization. An appeal filed on time usually lets the patient stay while it is decided. Medicare Advantage plans have their own appeal steps too.