Dad Was Just Discharged From the Hospital
The 30 days after a hospital stay are the most medically vulnerable of an older adult's life. Nearly one in five Medicare patients is readmitted within that window — most preventably.
Overview
Hospital discharge often happens quickly, with a folder of paperwork and a list of follow-ups that assumes someone is coordinating them. That someone is usually family. Understanding what level of care your loved one now needs — and how to arrange it before they leave the hospital — is the single most important thing you can do to prevent readmission.
Clinical explanation, in family-friendly language
Post-acute care in Arizona typically follows one of four paths: home with home health (Medicare Part A skilled services, time-limited), a skilled nursing facility (SNF) for short-term rehabilitation, an inpatient rehab facility (IRF) for higher-intensity therapy, or long-term care placement if recovery to prior baseline is not expected. Discharge planners are required to offer options — but they are not required to help you evaluate them. Common post-discharge risks include medication reconciliation errors, missed follow-up appointments, undertreated pain, and delirium in the first 72 hours home.
Common warning signs
- Confusion, agitation, or 'not acting like themselves' in the first days home
- New shortness of breath, weight gain, or leg swelling
- Difficulty managing the discharge medication list
- Falls, near-falls, or refusing to get out of bed
- Missing the first post-discharge PCP visit
Frequently asked questions
What is the difference between home health and home care?
Home health is Medicare-covered skilled nursing and therapy for a limited period after a qualifying event. Home care (also called non-medical or private-duty) is help with bathing, meals, and supervision, typically paid privately or through ALTCS.
Do we have to accept the SNF the hospital recommends?
No. You have the right to choose any Medicare-certified SNF with an available bed. An AdvaCare navigator can present you with vetted Arizona options in hours, not days.
How long will Medicare pay for skilled rehab?
Up to 100 days per benefit period if criteria are met, but daily copays begin on day 21. Coverage continues only while measurable progress is documented.
When to seek professional guidance
- Before the discharge plan is finalized, not after
- If the discharge destination doesn't match what the family can safely support
- When medications, oxygen, or equipment aren't in place before arrival home
- If your loved one has been hospitalized twice in six months
Care options to consider
- Skilled nursing facility (short-term rehab)
- Home health with physical, occupational, or speech therapy
- Non-medical home care for ADL support and supervision
- Assisted living with on-site therapy partnerships
Arizona-specific resources
- Medicare.gov — Care Compare for Arizona SNFs and home health agencies
- Arizona Long Term Care System (ALTCS) — for those meeting clinical and financial criteria
- Aging & Disability Resource Center of Arizona — 1-877-521-3500
Suggested next steps
- 1Request the discharge summary and updated medication list in writing
- 2Schedule the first PCP follow-up within 7 days
- 3Have an AdvaCare navigator vet post-acute options before discharge
- 4Confirm equipment and home health are scheduled to arrive on day one
You don't have to figure this out alone.
An AdvaCare navigator will listen, translate the clinical picture into plain language, and help you decide what to do next — at no cost.
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