What To Do When Your Elderly Parent Is Discharged From the Hospital

My father was in the hospital; he was getting out but he was never going home. I had just been told in a meeting with his doctors that I needed to find a memory care facility for him and I had five days to do it. After that meeting I drove across town to a different hospital. I wanted to be there when another doctor told my mother she had ovarian cancer and three months to live. Her next stop would be a skilled nursing facility as she was weak and needed to rebuild her strength. That would give me a week, maybe two, to figure out where she was going to live for the remainder of her life. Her home was no longer an option if my father wasn’t going to be there. 

The next day I stopped in to visit my mother during my lunch hour. The doctor and a social worker were in her room when I got there. “We have good news,” the doctor said. “Your mother walked with a walker today and she is stronger than we thought. She can go home today.”

“Home where?” I asked. “She can’t go home and be alone.”

“Well then take her to your house,” the social worker said.

How’s that for hospital discharge planning?

Luckily, for many adult children a hospital discharge usually comes with a more positive prognosis. You’re happy that your mother or father is feeling better but your role as caregiver probably just got a lot more complicated. And notice? There’s a good chance that no matter what the situation is that you get as much notice as I did, aka none. Your parent may be out of the woods, but you feel like you are about to enter them.

Hospital discharge planning is key. Experienced caregivers know that the time to develop the discharge plan is the minute your parent is admitted but those new to the role can find themselves scrambling to make post-hospital arrangements. Whether this is your first discharge experience of third, here’s our guide of what to do when your elderly parent is discharged from the hospital.

Download the Hospital Discharge Checklist here.

Caregiver Checklist Discharge

Get a written discharge plan.

Make sure you get a discharge plan – in writing – from the hospital. A discharge plan should include information on:

  • the appropriate post-hospital destination for a patient (i.e. home, skilled nursing facility, memory care unit, short-term rehab, etc.), as well as a list of facilities to consider
  • what the patient will need for a safe transition from the hospital to the post-hospital destination (i.e. ambulance, ride from family or friend, oxygen en route, etc.)
  • what services and treatment and care the patient will need post-discharge.

In other words, the plan should cover the medication list, what services, if any, your parent needs to line up (ex. physical therapy, occupational therapy), any diet restrictions, when to change bandages, when to follow up with the primary care physician and other specialists, etc.

Pro tip: I always ask the doctor or nurse what should prompt a call — which symptoms and side effects are normal and which ones should I be concerned about. I also like to know which doctor to call – the one from the hospital, the PCP, the specialist? Knowing the things that are out of the norm helps alleviate my concerns that I will miss something or that I will err on the side of not worrying enough or worrying too much.

Review the discharge plan with a doctor or nurse in person.

Review the written plan with the doctor or a nurse, in person, before you go. I always repeat the discharge instructions back to the doctor or nurse in my own words and ask them to confirm if what I heard is accurate. It’s not enough for them to repeat what they already told me. I need to internalize it and I don’t mind making them wait while I do that. This sometimes means really asserting myself so the doctor or nurse takes the time to stop and review the plan and then listen to me, not cut me off.

Check your feelings.

Your emotions may be on overdrive at the time of discharge. You’re nervous about what’s next and you may feel blindsided by the timing. Be aware of these emotions and don’t take them out on the hospital staff. Be respectful and listen to the care team; they are experts. But do know your top priorities are 1) to advocate for your parent – you know them best – and 2) to get all of the information you need. Once your parent leaves the hospital you are in charge. You need to know what you’re doing. Before they leave the hospital is the time to make sure you do.

Know your rights.

Upon admittance to a hospital, a patient should receive a patient bill of rights as well as information on the discharge process and how to appeal it. If you don’t see that information among your parents’ papers, ask for it. Discharges can be appealed. Per the Medicare website (www.medicare.gov), “If you believe you’re being discharged from a hospital too soon, you have the right to immediate review by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your area.” The hospital can connect you or you can visit the Medicare website for contact information.

The hospital must keep your parent while the appeal is resolved and Medicare will cover the extra time spent in the facility, excluding any deductible or copays for which your parent is responsible.

Before you appeal: Make sure staying in the hospital is really the best option. Hospitals are full of sick people after all and they are a great place to catch an infection.

Know if your parent was actually admitted and for how long.

This may sound crazy since we are talking about discharge from a hospital stay, but was your parent actually admitted and if so for exactly how long? Sometimes hospitals keep patients for observation but don’t actually admit them. This makes a difference in what benefits Medicare will pay for post-hospitalization. Also, if your parent is discharged to a skilled nursing center or rehab, Medicare won’t pay for it unless your parent stayed in the hospital at least three days. Well, that sounds simple, you’re thinking. Really? What constitutes an overnight at the hospital? Does a patient need to be admitted by a certain time of day or stay past a certain time of day? Ask! Don’t assume.

Plan transportation for discharge and all follow on appointments.

You will need to review transportation options with the hospital discharge planner. Important: consider not only transportation from the hospital, but also to any follow up appointments. If you need to be at work, and your parent has multiple post-discharge appointments to schedule, you need to make arrangements for that too. You may be able to arrange for some services to be offered in your parent’s home, which will cut down on the need for arranging rides. My Dad requires weekly blood tests so I have a nurse go to the assisted living facility to draw the sample and insurance pays for it. I cannot miss work weekly to take him to the lab.

Ask the discharge coordinator what your options are for leaving the hospital. If your parent isn’t heading home after their hospital stay but instead is going to another facility, an ambulance may be covered by insurance.

Pro tip: Tell the care coordinator what kind of car you drive and ask whether it is suitable for transporting your parent. I once owned two cars: a big SUV and a tiny sports car. Neither worked for taking my mother home post surgery. She couldn’t climb up into the SUV and she couldn’t lift herself out of the low seat in the sports car. I had to borrow a car to take her home safely.

Pace yourself on discharge day.

On the day of discharge, you will receive a call that your parent is ready to be released. That may be true but most likely the hospital is not ready. Do not stress if you can’t get there right away. Your parent will not be thrown out. They will either stay in their room until you arrive or be placed in a discharge waiting lounge. Your parent may be cranky if you don’t show up right away – just shake it off. You are starting a new phase of caregiving and you need to pace yourself. If you need to finish up assignments at work, or run some errands, or get the kids off to school, do it now.

When you get to the hospital you will most likely wait – even if you kept the hospital waiting. You will wait for the care coordinator to meet with you and review the discharge plan. You may have to wait while your parent gets dressed. You can of course use this time to sit and talk with your parent but don’t be surprised if they doze off. Hospital stays are exhausting! Bring something with you like a laptop or pile of work papers or a good book so you don’t waste precious down time.

Rent-A-Sister lets you go to, and focus on, work while we handle the caregiving details that don’t require a family member. Learn more.

If your parent is going home:

Skip town.

No, not really. But you may want to make yourself a little less available. Often, hospital social workers base discharge plans – whether a patient can go home, how much help a patient needs, what services they will refer for a patient (and how they will present those services to the insurance company for payment), on whether or not there is family in the area. And by family in the area, I mean just that. Hospitals and insurance companies, in my experience, do not care if you work part or full time, if you are the breadwinner, whether or not you are raising children or have other commitments. If you live in the same or a neighboring area code, the hospital typically assumes you will be the primary caregiver. If you are not prepared, available, or willing to assume that role, make sure you let the hospital know, in no uncertain times that you cannot be available. Tell them if you have others to care for. Tell them if you will be at work from 8 am to 6 pm or traveling on business. Make sure they know that if you can not be the live-in caregiver – unless that’s what you plan to do. Most hospital discharge guidelines call for the social worker or care coordinator to factor in the availability, willingness, and ability of family members to provide care.

Work with the hospital to line up services.

You will want to work with the care coordinator to line up whatever services your parent will need post discharge. Medicare-participating hospitals are required to provide a list of Medicare-certified home health agencies that participate in the Medicare Program and request inclusion on the hospital’s list. Know that the care coordinator is prohibited from directing you or your parent toward any particular agency so you may need to rely on referrals from other people (This is where support groups can help – join ours!) or be prepared to make adjustments after the fact if you are not happy with the services.

Schedule a visit with your parent’s primary care doctor.

The hospital should provide your parent’s primary care provider with a summary of the hospital stay including the reason for hospitalization, treatments that were administered, the medication plan and the follow-on care plan. There is a very good chance this information will not make it to the primary doctor’s office before your follow up visit. Pro tip: Ask for a copy from the hospital and fax it or email it yourself in advance of your appointment.

If your parent is going to another facility:

Get referrals – the easy way.

If your parent is not going home post hospital stay – they may need to spend time in a skilled nursing facility or a rehab, perhaps they are going to a memory care unit or hospice home, or maybe it’s time to move them to assisted living – you want to make sure the facility meets your standards and is convenient to you. However, you may not have enough time (or notice) to visit local facilities. Know this:

The hospital should have a complete and reasonably up-to-date list of facilities. The social worker or care coordinator will call and check on bed availability but you need to be the advocate and push for the facility you want, not just the first available. The hospital should make every effort to find a facility that meets your parent’s and or your preference. If they cannot, you have a right to know the reason. I once had a social worker try to place my father in a facility 90 minutes from my home. She told me my convenience was not a factor in his placement and that I had to take the first available bed. I countered that as his healthcare proxy and daughter, my ability to visit the facility daily was a critical part of his care. She found him a bed closer to home.

You can hire someone to research and visit facilities for you. Many don’t charge you a fee. Download the checklist for choosing a senior living referral agency.

Medicare keeps a list and rating of facilities. It’s not a perfect way to choose a placement, but it can be a way to narrow down choices or make a decision when you have no time. Click here to access the database. You can search facilities by zip code.

Be present as much as possible the first few days.

When your parent is checked in to the new facility, be there as much as your life allows the first few days. Get to know the new care team. Your job is to let the staff know you are present in your parent’s life and available to them as part of the care team. Be friendly and respectful – but remember you are your parent’s advocate first.

Learn the schedule so you can advise visitors the best times to stop by and the times to avoid. Ask when the best times are for updates. If your parent moves in after 2 p.m. or on a weekend, do not expect any meaningful updates until the next business day.

How to manage your own life:

When your elderly parent is discharged from the hospital, a new phase of caregiving begins. You may think an ordeal is ending. That’s true. But it’s time to accept a new normal. Here are some tips to cut down the chaos in your life:

  • Involve your spouse and kids in your decisions. Caring for an aging parent can strain even the strongest relationship. Do not cut your partner or children out. Let them know what you’re doing and why you are doing it. Ask for their support and thank them when they give it to you.
  • Ask for and accept help. This is the time to ask for – and accept – help. Keep a list with you at all times of all the things you need to do. When someone asks, “How can I help,” consult the list and give them a task. Don’t just take help on behalf of your parents. Accept help running your own errands too. Let people pick up your kids from school or drop off your dry cleaning or make you a meal. By helping you, they are helping your parent too.
  • Make a plan for how much you can manage at work. Do you need to take time off from work after your parent is released from the hospital? Only you can make that call. If your parent is not receiving services covered by insurance or you cannot afford to hire outside care, you may need to take some time off or cut back on assignments or hours. The Family Medical Leave Act allows for unpaid, job-protected leave for eligible workers. You could get 12 workweeks of leave in a 12-month period to care for a parent who has a serious health condition. The tricky part is eligibility. You must meet these requirements:
    • work for a covered employer
    • have worked 1,250 hours during the 12 months prior to the start of leave
    • work at a location where the employer has 50 or more employees within 75 miles
    • have worked for the employer for 12 months.
  • Be forgiving. Forgiveness is key post-hospital discharge. Your parent may be demanding or frustrating. They may be scared. Medications might affect their mood. They could be mourning the loss of independence. Take deep breaths. Go for walks when and if you can. Be as patient as you can muster. And forgive yourself. You will mess up. You might be snappy and inpatient. There is no training for family caregivers. You are doing the best you can.

Let Rent-A-Sister handle all of the details during and after your parent’s hospital stay.

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20 comments on “What To Do When Your Elderly Parent Is Discharged From the Hospital”

  1. Kim Tackett Reply

    I’m dealing with all of these issues right now. Mom came home from hip replacement surgery, and I was the nurse. Dad can’t care for her, and is used to being cared for BY her (he has more health issues than she does). I have a life 500 miles away. So I have been there 4 out of the last 6 weeks (including flying down for followup doc appointments). Working on keeping them safe in their own home, and convincing them to move to my town. Hopefully, we will have time…but not so sure. Sigh.

    • admin Reply

      Yikes Kim, that’s a lot to deal with. Let us know how we can help – glad you found us.

  2. Joe Nicholas Reply

    I’m desperate. I feel trapped in my own home. An elderly neighbor moved in after my divorce years ago. It was money saving & convenient almost ten years ago. Now, I’m not a house mate but a servant. I clean feces and urine several times a day from commode and surrounding areas. I’ve called twenty nearby nursing homes. None will mail an application. I’m one man. I don’t have any realtives or friends helping. I have no family and he has no one. I can’t watch him And tour a facility. I literally don’t ever have a day off. If I ask his primary physician to place the patient in hospital and then tell hospital he cannot come here after, won’t a hospital social worker be forced to find a nursing home? Any advice or ideas would sincerely be appreciated.

    • admin Reply

      I am sorry for your stress, and my delayed response. I had a very serious illness in my family to deal with in the last month. Yes, if you make yourself “unavailable” the hospital will act accordingly. Ideally, there is a third solution – that you insist his primary help you place him somewhere you feel good about and help hook you up with the resources you need. Not all medical doctors treat holistically so it may not work. Have you tried elder affairs in your town or city?

  3. Yas Reply

    Good morning ! My situation is the following, my mother suffered a stroke on June 13, and we decided to bring her to the house after discharge in jun 27 because she did not want to go anywhere else. he has problems with his right arm and right leg. I have tried to help her abut she does not cooperate, she can feel and talk when she is doing pipi or popo but she prefers to do it in bed. She make me crazy, I had in the past mayor depression andshe is very difficult person. 4 days ago I bring her to my home after discharge. , which she had to do to take her to a place where she can stay until she finishes her therapies, because she needs to be seen, bathed, medication, . I call the social worker at the hospital today and she told me that regrettably once she leaves the hospital, it is difficult for the insurance to accept receiving it in a place of care. What can I do?

    • admin Reply

      I am sorry you and your mother are going though this. Ask the social worker to go back to the insurance company for you. Make sure you let them know you cannot provide care. If they think family is avaialble that is the first choice for them. But you need to manage your health too.

      • Yas Reply

        Thanks for your prompt reply! The social worker told me that it was very difficult the insurance do something after she leave the hospital. I do not know how or where to start after the social worker told me that today. My mom has 3 children but none of the others two has been present. Also I had a 6 month follow appointment two years ago and I could not go, because my brother seriously ill and died last year. I had to stop going to make my medical appointments to come attend my brother until he died because my mom gave me all the responsibilities on my shoulder. In my family there is a history of cancer . in only 4 days my mom is already driving me crazy.

      • Yas Reply

        I have my depression record with me and my certified letters where said that I had to have a mammogram in 6 months and it had been a year and I still had not gone. My mammogram was two years ago. either I live in NJ and my mom in Florida. I leave my home my husband two years ago in the house to come and take care of my brother, my husband also pays the rent of the house where my mother lives because he wanted me to be comfortable. But my mom is very difficult, she does not cooperate, she does not do her exercises, she does it in bed and last night she got out of bed and she only has mobility on her left side. The truth is that I don’t know how she get out of bed, but I can not deal with her doing all those things.

  4. Sue Reply

    My 89 year old father is in the hospital and it was deemed my stepmother cannot care for him as he is combative, has dementia and now has blood clots in his bladder. It was decided to just treat the symptoms and not even try to find the reason. They have given his care over to a caseworker and my stepmother is insisting that we not interfere or ask questions. What might be the downside of turning over his care to the caseworker? I believe they will move him into a nursing home after his hospital stay.

  5. Ellen Reply

    My mom was moved to the rehab floor 3 hours too soon from the acute floor while she was at the hospital, now her skilled nursing center is telling me they can’t extend her stay because the she didn’t stay for full three days on the acute unit. Her TP said it’s a critical time for my mom who is a stroke patient to get therapy sessions. She can’t live without skilled nurse’s support, and I’m a single mom with a senior in high school who is ready to go off to college. Any advice?

  6. Renee Reply

    Has anyone dealt with their parent being discharged from Rehab and no home inspection has been completed for your parents safety? Medically she is better and does not need the medical care BUT she is 96 lives a condominium that is 3 levesls — stairs stairs stairs, discharge planning is somewhat dismissing my mothers concerns for her mom’s safety. What is her next step to get help?

  7. Nancy Reply

    My grandfather. He has dementia and now has blood clusters in his bladder. It was chosen to simply treat the side effects and do whatever it takes not to discover the explanation. They have given his consideration over to a case manager and my stepmother is demanding that we not meddle or pose inquiries. What may be the drawback of giving his consideration to the case manager? BTW thanks for this beautiful article.

    • admin Reply

      Hi- unfortuntaly I don’t know what you mean by giving his consideration to a case manager? But i think it’s always ok to ask questions.

  8. Lili Reply

    My mom is in Rehab and has been there for the last 5 wks. She will be discharged in 5 days. The social worker asked if I can provide a safe home for her. I’m nervous because I’m not sure I can. What happens if I tell the social worker that I cannot provide a safe home for my mom? What happens to my mom?

    • admin Reply

      They may choose to send your mother to a rehab for a few weeks or they may bring in services to support her like a visiting nurse. But if you can, ask the social worker without committing to anything. Family members are typically the default discharge plan.

  9. sonia hickman Reply

    My friends mother was in the hospital she has some mental issues. No one informed him where they transferred mom to. Hospital won’t release information to him and say where she is. He’s been looking at different hospitals and rehabs no one will help him. He doesn’t know where she is. Please help.

    • admin Reply

      How upsetting. I assume they won’t release the information due to HIPAA laws. Perhaps your fried can find out who his mother’s healthcare proxy is and have that perosn find out or maybe the hospital that transferred her can deliver a message to the proxy on his behalf.

  10. crystal Reply

    My mom was diagnosed with cancer (unknown stage/origin) about a month ago and was discharged. Then had a stroke not 3 days later. I got her into a intensive rehab facility post the stroke and she’s done well but is still wheelchair bound needs alot of help and mentally is very much in the present and doesn’t have good planning or focus. Making decisions for and with her are difficult. I manage to get her an oncology appointment and the rehab did transport. Stage IV probably pancreatic.

    To add to this, her current residence is a 2nd floor apartment (18 stairs she’ll never get up) with a lease ending beginning of May. I’ve tried since she’s been at rehab to get her another apartment only to burn $400 in apps till I finally learned she never paid last months rent at her previous place and she is insta denied during a credit check. I’m not sure how much she really grasps. She keeps asking me how the apartment hunt is going and I’ve told her a few time I can’t get her a place to live because of the credit ping.

    The facility knows the living situation. They also know I can’t bring her to my home, I already care for my disabled son and I live 2 hours away. By all accounts my mother is homeless right now. They are currently working to move my mom to a skilled nursing facility but I’m feel like im grinding gears here.

    I have follow ups to get her to for neurology (no call for appointment when I called their office closed) – PET scan needs done but nobodies called to schedule that either AND if she’s inpaitent insurance won’t cover the scan – but I think I can fight them on that.

    COVID-19 isn’t helping either as the world is on lock down.

    I feel like I’m failing at everyturn, and every possible road block is beating me up. I’m trying not to let it beat me down but man it’s getting harder day after day. Each day is a day lost with cancer and we’ve lost soooo many.

    • admin Reply

      I am so sorry. My husband had pancreatic cancer. Can her oncology team help? Many hospitals now take a team approach to care and include a social worker and a a palliative team that may have some resources to help you come up with a plan – and give you some support and counseling too. Cancer caregiving is a job. Hang in there! Wishing you the best.

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