Leaving Strong, Highland, Rochester General or Unity: A Discharge Checklist for Families

Why the hospital is where it starts

Monroe County's 5 acute-care hospitals, run by UR Medicine and Rochester Regional Health, discharge thousands of older patients a year to rehab, assisted living or home. The decision often has to be made in two or three days. Families who know the steps in advance make better choices and fewer emergency ones.

The checklist

Observation status, explained

A patient can spend days in a hospital bed under observation without being formally admitted. For Medicare, only inpatient days count toward the three-day stay required for skilled nursing facility coverage. Hospitals must give a Medicare Outpatient Observation Notice to patients held under observation for more than 24 hours. If you receive one and expect rehab to follow, ask the physician whether admission is appropriate, and ask the case manager what it means for coverage. Medicare Advantage plans often waive the three-day rule but require prior authorization instead.

Choosing rehab without regret

The case manager will offer a list. Look each home up in our nursing home directory or on Care Compare: overall stars, staffing hours against New York's 3.5-hour minimum, the latest inspection and its deficiency count. Then weigh distance. A home ten minutes from the person who will visit every day often produces a better recovery than a better-rated one an hour away. Ask whether the rehab unit is separate from long-term care, and how many therapy sessions a day patients usually get.

When the plan is assisted living or home

Assisted living residences must assess a new resident and receive a medical evaluation completed within the last 30 days. Hospitals can produce one quickly if asked. If the parent qualifies medically for a nursing home and has limited means, ask the case manager to refer to Assisted Living Program providers as well. For a discharge home, confirm the home health agency, the start date of the first visit, and who to call if the visit does not happen.

Medications, the most common point of failure

The medication list is where discharges most often go wrong. A hospital stay can stop some long-standing medications, start new ones and change doses, and the discharge summary may not match what is in the pill organizer at home or what the assisted living residence's pharmacy has on file. Before leaving, ask the nurse to walk through the list line by line: what is new, what stopped, what changed and why. Take a photo of the list.

If the parent is going to an assisted living residence, send the list to the residence the same day and confirm who will fill the new prescriptions. Adult home staff can assist with self-administration but cannot interpret changes; the residence's affiliated home care nurse or the parent's own doctor needs to reconcile them. For a discharge home, ask the home health nurse to review medications at the first visit.

The first two weeks after discharge

Readmissions cluster in the first few weeks home. Schedule the primary care follow-up before leaving the hospital, ideally within seven days, and bring the discharge papers. Watch for confusion, falls, poor eating and breathing changes, and call the doctor or the home health agency early rather than waiting for a crisis. Medicare's home health benefit can send a nurse and therapists to a homebound patient, including in assisted living, if the hospital physician orders it.

For family caregivers, those two weeks are also the hardest. Ask NY Connects about short-term help, line up meals, and accept offers from friends. If it becomes clear that home is not working, call the residences on your list right away rather than waiting for the next hospital stay to force the decision.

If something goes wrong after discharge

Call the hospital's discharge line or the patient's primary care office first. If a nursing home later tries to discharge a resident in a way that seems wrong, New York's Nursing Home Complaint and Discharge Appeal Hotline is 1-888-201-4563.