Guidance · Hospital to home
12Questions
to bring with you
Ask what was ordered and who provides it, how many hours Medicare covers, when the first visit is, who helps in between, and which number to call. Bring this list and write the answers down.
Questions to Ask Your Hospital Discharge Planner
Endurance Home Care, the home care agency at 60 Long Ridge Rd in Stamford, CT, put together these questions to ask a hospital discharge planner, so your family leaves knowing what was ordered, what Medicare covers and who will help at home.
It’s fine to ask questions before a discharge, and hospitals expect it. The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination, to engage patients and caregivers in discharge plans, and in turn to reduce avoidable readmissions.
The planner will have answered these questions many times. The list below comes in four groups, in the order a discharge meeting usually goes, with space to write each answer. For the bigger picture, see our guide to transitional care after a hospital stay.
- Group 01
What was ordered
- Group 02
Hours and limits
- Group 03
Timing
- Group 04
Paying, and what to bring
What was ordered
Start with the paperwork, because everything else depends on it. For Medicare home health, a health care provider must order the care and a Medicare-certified home health agency must provide it, so the planner will know which services were ordered and which agency is providing them. Ask for the agency by name and write it down. Then ask whether your parent qualifies: Medicare covers home health only for people who need part-time or intermittent skilled services and who are homebound as Medicare defines it. Both have to be true.
Write the answer down
Which services are ordered, and who signed the order?
Ask for names, so you know who to call later.
Which agency is providing them, and is it Medicare-certified?
Medicare requires a certified agency for the covered visits. Ask for the name and a phone number.
Does my parent meet both Medicare conditions, skilled need and homebound?
Ask for a plain yes or no on each condition separately.
If the answer is no, which of the two conditions is the one that fails?
It changes what you arrange next, and how soon.
The key question
Part-time or intermittent skilled need, and homebound, both true at once?
Medicare home health can go ahead on its own terms: covered visits you pay nothing for, with limits on the hours and on what’s included. Take our discharge checklist to fill out along the way, and see the hours below.
Help at home is still possible. Home care needs no doctor’s order and no homebound status, and families arrange it directly. That’s transitional care from Endurance, for the days and weeks after a discharge.
How many hours does Medicare cover?
8 hours a day. 28 hours a week.
Ask for the hours before you leave the meeting. In most cases Medicare defines part-time or intermittent care as skilled nursing care and home health aide services up to 8 hours a day combined, for a maximum of 28 hours a week. That averages out to about four hours a day.
Two more things are worth knowing. People eligible for the Medicare home health benefit pay nothing for covered home health services. And the benefit doesn’t pay for homemaker services, like shopping and cleaning, that are unrelated to the care plan. Groceries, laundry, the ride to the follow-up and company on a quiet afternoon are arranged separately. That’s the help our caregivers provide, along with hands-on personal care. We provide personal care in Connecticut and New Jersey. In New York we provide companion care, by the hour, overnight, live-in or around the clock.
How many hours a week are covered, and across how many visits?
Hours and visits are different answers. Ask for both.
What will we be billed for the covered visits?
What is not covered at all under this plan?
Housekeeping, errands and company often fall here.
Who helps on the days and hours no visit is scheduled?
The first visit has a date. Ask who helps before it.
Ask for a specific day and time while the planner is with you. Then ask who will be in the house between coming home and that first visit, including the first night. Endurance Homebound is our plan for the first 72 hours after discharge, and you can read what happens in the first 72 hours after discharge in more detail.
What day and time does the first visit happen?
Who is in the house on the first night, before that visit?
What changes mean we should call, and which number do we call?
Ask for the number that is answered after hours, and write it on the discharge papers.
Bring the policy along with the questions.
If your parent has long-term care insurance, bring the policy along with the discharge papers, a list of the daily routines someone now needs to cover, and a pen. Families can use a long-term care policy for home care, and we help with the policy paperwork. Endurance sits down with families, reads the policy alongside them, and lays out what it looks like the policy will and won’t cover. Endurance is private pay and doesn’t bill insurance directly.
What should I bring to this meeting, and to the next one?
Questions families ask
What questions should you ask a hospital discharge planner?
Start with five. Which services were ordered, and which agency provides them? Does my parent meet Medicare's home health conditions? How many hours are covered, and what falls outside them? When is the first visit, and who helps before it? Which changes mean we should call, and which number do we use? Write the answers on the discharge papers so they stay together.
Who qualifies for Medicare home health after discharge?
Two conditions, both required: the person must need part-time or intermittent skilled services, and must be homebound as Medicare defines it. A health care provider must order the care, and a Medicare-certified home health agency must provide it. Ask the planner directly whether your parent meets both conditions, and get it in writing.
What if my parent does not qualify for Medicare home health?
Help at home is still possible. Home care needs no doctor's order and no homebound status, and families arrange it directly with an agency like Endurance. Help with bathing, meals, rides, reminders and someone nearby are all available this way. Endurance is private pay, and a long term care insurance policy may help pay for it. If there's a policy, families can use it, and we help with the policy paperwork.
Tell us what the planner said.
We’ll tell you what it leaves you to cover, and talk through the help your parent will need at home around any visits that were ordered, from an agency licensed by the state. The first conversation is free, and nothing starts until you say so.