Sort the first week home before they leave the hospital

Medicare publishes a discharge checklist for patients and caregivers, and it says the caregiver is a member of the planning team. Use that. Ask for the discharge planner, social worker or nurse by role, and ask the checklist's own questions:

• "Ask where you'll get care after you're discharged. Do you have options (like home health care)? Tell the staff what you prefer."
• "Ask if you'll need medical equipment (like a walker), if it's covered by Medicare, and who will arrange for its delivery."
• "Ask for written discharge instructions (that you can read and understand)" and take them to the follow-up appointment.
• For you, the caregiver, the checklist says to "talk to the staff about getting the help you need before discharge" and to "write down the name and phone number of a person you can call if you have questions."
• The checklist's list of activities to ask about is worth reading out loud: bathing, dressing, using the bathroom, climbing stairs; cooking, food shopping, house cleaning, paying bills; driving to appointments, picking up prescriptions. Circle what your parent will need help with. That circle is your first week.

Source: Medicare, Your Discharge Planning Checklist, CMS product 11376, December 2025.

If your parent is on Medicare, the hospital should hand over a notice with that title. Medicare says you should get it "within 2 days of your admission and prior to your discharge." It sets out the right to a fast appeal if you think the discharge is too soon, reviewed by an independent organisation Medicare calls a BFCC-QIO.

• Ask for the notice by name if nobody has given it to you. The discharge checklist says plainly: "If you don't get a notice, ask for it."
• Read the deadline on it. Medicare's rule is to follow the directions "no later than the day you're scheduled to be discharged from the hospital."
• Know what the deadline buys. If the appeal is filed in time, "you can stay in the hospital while you wait to get the BFCC-QIO's decision," without paying for the stay beyond the usual coinsurance and deductibles.
• Know what missing it costs. Medicare says you can still ask for a review, "but different rules and time frames apply, and you might be responsible for the cost of the hospital stay past the original day the hospital tries to discharge you."

Whether to appeal is not a question this page can answer. Whether you have the notice in your hand is, and the answer should be yes before anybody packs a bag.

Source: Medicare, Fast appeals; Medicare, Your Discharge Planning Checklist.

The discharge planner will talk about "home health." That is Medicare's clinical service, a nurse or therapist visiting on a doctor's order, and it is a different thing from the help at home this site is about. In the first week you may need both, and they are arranged in different places.

• Home health is ordered, not booked. Medicare requires that "a health care provider (like a nurse practitioner) must assess you face-to-face before certifying that you need home health services," and it must be "part-time or intermittent skilled services." The hospital arranges it through a Medicare-certified agency. Medicare's booklet says "you have a say in which agency you use," and points to Care Compare to look one up.
• Help at home is what Medicare does not pay for. Its list is short and worth having in writing: "24-hour-a-day care at home," "meals delivered to your home," "services like shopping, cleaning, and laundry," and "custodial or personal care like bathing, dressing, and using the bathroom (when this is the only care you need)."
• If a home health agency offers something Medicare will not cover, it owes you a form. Medicare says the agency "must give you a written notice called an Advance Beneficiary Notice of Noncoverage (ABN)" before giving a service Medicare probably won't pay for, including when "the care is only nonskilled personal care, like help with bathing or dressing." Ask for it if the conversation turns to hours of sitting.
• Ask which entity each hour belongs to. If one company is offering both, get the clinical visits and the non-medical hours on separate lines of the quote, with the payer named on each.

Source: Medicare, Home health services; Medicare, Medicare & Home Health Care, CMS product 10969, July 2025, sections on what isn't covered, choosing an agency and the ABN. The category difference on the Missouri side is set out, statute by statute, on the sister desk's two categories page.

• Equipment needs an order. Medicare Part B "covers medically necessary DME if your doctor or other health care provider orders it for use in your home." Ask the planner who is writing that order and who the supplier is.
• Check both ends. Medicare's advice: "Make sure your doctors and DME suppliers are enrolled in Medicare."
• Ask for a delivery day and a phone number, and ask whether it arrives before your parent does. A walker that turns up on Thursday is not much use to somebody who came home on Tuesday.
• Walk the house for where it goes. If a hospital bed, a commode chair or a walker is coming, the route from the bed to the bathroom changes. The room by room checklist is the tool for that, and it is worth doing before the delivery, not after.

Source: Medicare, Durable medical equipment (DME) coverage. The items Medicare names include canes, commode chairs, hospital beds, walkers and wheelchairs.

The first follow-up appointment is usually inside the week, and the fridge is usually empty. Both are logistics, and both have a public front door.

• Call the Area Agency on Aging that covers the address. The NIA's advice for arranging services at home starts with the Eldercare Locator, which "can help you find resources in your area, including in-home help and transportation." In this region that resolves to one of three agencies, and their numbers are on their own page. The national line is 800-677-1116.
• Ask about home delivered meals. The NIA notes meal delivery programs "bring healthy, nutritious meals to a person's home on a daily or weekly basis," that some require a person to qualify, and that "the delivery staff do not assist with making meals at home or feeding the person." Know which of those you need.
• Book the ride to the follow-up now. The NIA lists state and local agency transportation, discounted public transit and ride services, and says "if needed, you can request a vehicle that will accommodate a wheelchair, walker, or electric scooter." Ask how far ahead the booking has to be made.
• Set up the errands. The NIA's plain suggestion: "Some grocery and drug stores will take orders over the phone or online and deliver the items to a person's home." Do the first order before discharge.

Source: NIA, Services for Older Adults Living at Home, content reviewed October 12, 2023; Eldercare Locator, a public service of the Administration for Community Living.

The NIA's guidance on sharing the work is written for the long haul, and it applies twice as hard to a single week with a fixed start date.

• Name one person. The NIA says "many find that the best first step is to name a primary caregiver," the one who "takes on most of the everyday caregiving responsibilities," so that person "can step in right away if there is a crisis."
• Split by task, not by day. "The next step is to decide who will be responsible for which tasks," ideally matching each person to "the tasks best suited to their skills and interests." Who does meals, who does the ride, who does the pharmacy run, who sits the first night.
• Keep one notebook. The NIA suggests a caregiving notebook with "contact numbers" and other details, kept "in a central location," on paper or on a phone, and reviewed regularly. The discharge instructions and the who-to-call list from stop 01 go in the front of it.
• Write the who-to-call list in large print and tape it where the phone lives. Doctor, pharmacy, the discharge contact from stop 01, one neighbour, the Area Agency on Aging. The same list the room by room page asks for, updated for the week.
• Check in at the end of the week. The NIA's own instruction is to "check in with the older person and the other caregivers regularly to make sure the current arrangement is still working for everyone." Day seven is the first check.

Source: NIA, Sharing Caregiving Responsibilities, content reviewed October 12, 2023. The NIA also publishes a coordinating worksheet, linked from that page.