What Happens After Hospital Discharge? A Family Guide

The Critical 48 Hours After Discharge

Hospital discharge can feel rushed and overwhelming. Yet this transition is one of the most dangerous times for older adults—nearly 20% of Medicare patients are readmitted within 30 days. Here's how to navigate it safely.

Understanding Your Rights

The MOON Notice (Medicare Outpatient Observation Notice)

If your loved one is in the hospital under "observation status" rather than "admitted," Medicare coverage for rehabilitation may be affected. Always ask:

• "Is my loved one admitted or under observation?"
• Request written notice of observation status

The Discharge Planning Rights

You have the right to:

• Participate in discharge planning
• Receive written discharge instructions
• Appeal a discharge you believe is premature
• Receive information about post-hospital care options

Questions to Ask Before Discharge

About Medications

• What new medications were prescribed?
• What medications were stopped or changed?
• Are there any drug interactions to watch for?
• When should each medication be taken?
• What are the side effects to watch for?

About Follow-Up Care

• When is the follow-up appointment?
• Which doctor(s) need to be seen?
• What symptoms should prompt immediate medical attention?
• Is a referral needed for any specialists?

About Home Care Needs

• Does my loved one need home health care?
• What equipment is needed (walker, hospital bed, oxygen)?
• Are there activity restrictions?
• What diet changes are recommended?
• Who will provide daily care?

Post-Hospital Care Options

Home with Home Health Care

• Skilled nursing visits
• Physical/occupational therapy
• Medical social worker
• Home health aides

Medicare covers home health if homebound and need skilled care.

Skilled Nursing Facility (SNF)

• 24/7 nursing care
• Intensive rehabilitation
• Short-term stays (typically 20-100 days)

Medicare covers SNF after 3-day qualifying hospital stay.

Rehabilitation Hospital

• Intensive daily therapy (3+ hours)
• For stroke, hip fracture, major surgery recovery
• Medical supervision

Long-Term Acute Care (LTAC)

• For complex medical needs
• Extended hospital-level care
• Ventilator weaning, wound care

The Discharge Day Checklist

• [ ] Written discharge instructions received
• [ ] Medications picked up from pharmacy
• [ ] Follow-up appointments scheduled
• [ ] Transportation arranged
• [ ] Home prepared (grab bars, clear pathways, etc.)
• [ ] Emergency contacts updated
• [ ] Primary care doctor notified
• [ ] Medical equipment delivered
• [ ] Home health agency contacted

Red Flags After Discharge

Seek immediate medical attention for:

• Fever over 101°F
• Increasing confusion
• Severe pain not controlled by medication
• Difficulty breathing
• Falls
• Inability to take medications
• Signs of infection (redness, swelling, discharge)

Get Professional Support

A geriatric care manager can help coordinate discharge planning and ensure nothing falls through the cracks.

Related Resources:

• Download our Hospital Discharge Checklist
• Signs Your Parent Needs Home Health Care
• Care Coordination Services