Before the wheelchair reaches the curb
A Hospital Discharge Checklist for Elderly Parents
The hospital gives you a plan for the hospital. This is the list for the house you are taking them back to.
Endurance Home Care, the Stamford, CT family agency founded by brothers Chris and Tom Weldon, built this hospital discharge checklist for elderly parents around the tasks families hand us first: medications, rides, follow-up appointments, and a safe house to come home to.
Why the hospital plan is not the whole plan
The plan a hospital writes is a plan for the hospital part of this. Medicare runs a value-based program, the Hospital Readmissions Reduction Program, that encourages hospitals to improve communication and care coordination and to engage patients and caregivers in discharge plans, which is one reason the folder handed to you at the door is thicker than it used to be. It is still written from the ward. It names the orders, the follow-up, and the medications. It does not know which stair rail is loose, who is free on a Tuesday, or that nobody has stood in the kitchen in nine days.
The national picture is worth holding lightly and knowing anyway. Five conditions considered potentially preventable, heart failure, diabetes with complications, pneumonia, COPD, and urinary tract infection, accounted for 18.7 percent of hospital readmissions in 2020. That is a statistic about hospitals, not a prediction about your parent. It sits here because the household half of a discharge is the half nobody writes down, and this page is our attempt to write it down.
Endurance Home Care was founded by brothers Chris Weldon and Tom Weldon with their close friend Andrew Schwartz. The list below is the one families hand back to us first. For the wider picture around it, read our family guide to transitional care after a hospital stay.
Stage one, before you leave the ward
Six things to be holding when the doors open. Every one of them is easier to get while there is still somebody at a desk to ask, and considerably harder to get by phone on a Saturday.
- The written discharge orders, printed and in your hand before the wheelchair moves.Get it in writing
- A current medication list with every drug, dose, and hour on it, including the ones stopped this week.Ask for this
- The follow-up clinician named, with a date written down rather than promised.Ask for the date
- Which services were actually ordered, and which agency is bringing each one.Ask who
- Any equipment ordered, where it ships from, and what day it reaches the house.Ask when
- One phone number to call with a question at nine at night.Ask for this
The fourth line is the one families most often leave without. If a clinician ordered skilled nursing or therapy at home, that is Medicare home health, and it comes with rules: the care must be ordered by a health care provider and provided by a Medicare-certified home health agency. It arrives as visits, on that agency schedule rather than yours. Everything that is not a visit, the meals, the rides, the reminders, the hours when somebody simply has to be in the house, sits outside that order and stays yours to arrange. Ask which of the two you are being sent home with, and write the answer on the same page as the phone number.
Read next: the first 72 hours after discharge, hour by hour by hour.
Stage two, the house before the car pulls in
Walk the house once with a stranger’s eyes, along the paths that will actually be used, and fix what that walk finds. This is the half hour that pays for itself.
- Clear the path from the bed to the bathroom, and the path from the chair to the kitchen.Homemaking
- Light the hallway and the stairs, so nobody crosses a dark room at three in the morning.Homemaking
- Move the daily things to waist height. Nothing used twice a day should live on the floor or over the head.Homemaking
- Food in the kitchen that can be eaten without a plan, and a bin emptied before anyone arrives.Homemaking
- A pill organizer prepared by the client, family, pharmacist, or licensed provider, and a verbal prompt at the right hour.Medication reminders
- Somebody within earshot for the first nights, and a ride booked for the first appointment.Safety supervision
The tags are not decorative. Endurance’s listed services are medication reminders, transportation, homemaking, safety supervision, personal care, and companion care, and every line above lands inside one of them. Writing the list this way turns each item into work somebody can be booked to carry rather than one more job waiting for a daughter who already has one. The boundary stays hard in both directions: caregivers support, coordinate, remind, accompany, and supervise. They do not treat, diagnose, administer, or assess. Hospital-to-home care and personal care serve Connecticut and New Jersey; New York service is companion care only. Endurance Home Care provides care at home in Connecticut and New Jersey, with companion care only in New York. Skilled nursing, home health aides and physical therapy in Connecticut are provided by Endurance Home Health.
Stage three, the first week on one calendar
The useful question in week one is not what has to happen. It is who is bringing it. Set the two columns side by side and the gaps name themselves.
| What the week needs | Who the orders assign it to | What the household still arranges |
|---|---|---|
| Skilled nursing or therapy visits | Ordered by a clinician and delivered by a Medicare-certified home health agency. | The hours between the visits, which are not visits and are not part of that order. |
| The follow-up appointment | Named in the discharge orders. | A ride there and back on the date, and somebody sitting in the waiting room. Transportation. |
| Medications on schedule | Listed on the discharge medication sheet. | A prompt at the right hour. Caregivers remind. They never administer. Medication reminders. |
| Meals and a kitchen somebody can work in | Nobody. | Homemaking hours, from the first grocery run onward. |
| Not being alone at night | Nobody. | Safety supervision or companion care, on the nights the household is most improvised. |
| Whether the plan still fits in week four | Nobody by default. | Coordination of medical care and a customized monthly assessment, both of which Endurance is built around. |
Put all of it on one calendar, the household one, not the folder. Every appointment gets a ride attached to it in the same entry, because an appointment without a driver is a wish. Every medication hour gets a person attached to it. Then look at the empty squares, which are the real subject of this page: the afternoons and the nights nobody has claimed. Those are the hours a home care agency is for, and they are also the hours a family burns through goodwill trying to cover between jobs.
Build the calendar before the discharge date if you can. The questions that fill it in are short, and they are all easier asked in person, so take what to ask the discharge planner before you leave before the date is set.
A ticked list is only worth the person who turns up to carry it.
Before any caregiver is scheduled, a registered nurse conducts the client assessment, in the home, with the discharge paperwork on the table. That visit is where a checklist stops being generic: which paths matter, which hours are thin, which of the six services the week actually needs, and what the household would rather keep doing itself. Care plans are reviewed monthly after that, because the shape of a first week is not the shape of a fourth.
What an aide takes off your plate is specific rather than heroic: the grocery run, the meals, the prompt at the right hour, the drive to the follow-up and the wait through it, the path kept clear, and somebody within earshot on the nights being alone is the hard part. Nothing clinical, in either direction. If the list on this page has more empty squares than your family can cover, that is the ordinary reason people call, and transitional care support at home is the service built for exactly that stretch.
Connecticut License HCA.0002450 · New Jersey License HP0435100 · Connecticut DPH License 9915786 (Endurance Home Health). Hospital-to-home care serves Connecticut and New Jersey; New York service is companion care only.
Questions families ask before a discharge
What should be on a hospital discharge checklist for an elderly parent?
Five things before the car ride home: the written discharge orders and medication list in hand, follow-up appointments booked with transportation planned, the house set up for safety with food in the kitchen, a clear list of which services were ordered and who provides them, and one phone number for questions. Each item on this page maps to a service a home care agency can carry for you.
How do I make the house safe before my parent comes home?
Walk the paths your parent will actually use: bed to bathroom, chair to kitchen. Clear cords and rugs, light the hallways, put daily items at waist height, and stock easy meals. Safety Supervision and Homemaking are two of Endurance's listed services, and an assessment can flag hazards a family walks past every day.
What appointments happen after hospital discharge?
Your discharge orders name them: usually a follow-up with the hospital team or surgeon within days, then the primary care physician, plus any therapy. Put every date on one calendar with a ride attached to each. Endurance coordinates clients' medical care and provides transportation, which one family said takes a lot off their plate.
Bring us the list with the empty squares on it.
Daily-living care after a hospital stay, across Fairfield and New Haven counties, from an agency registered with the State of Connecticut.
Call (203) 936-6847