Coming Home From the Hospital

If your discharge plan includes home health, you have a say in which agency comes to your home. Ask for Comfort Care Home Health Services by name, and we will take it from there.

Here is what to expect, and what to ask before you leave.

Before you leave the hospital

The last day in the hospital moves fast. A discharge planner stops by with a folder of papers. A nurse goes over medicines while your dad is trying to get his shoes on. Then the wheelchair is at the door. It helps to know what to ask while everyone is still in the same room.

• Ask whether home health is part of the plan. If you think it is needed, say so.
• Name the agency you want. With Original Medicare, you have the right to choose any Medicare-certified agency that serves your area. Tell the planner, "We want Comfort Care Home Health Services." Medicare Advantage plans may limit the choice to their network, so ask.
• Get the medication list in writing. Ask which medicines are new, which changed, and which stopped. Keep that list next to the pill bottles on the counter.
• Get the follow-up appointment date and write it on the calendar before you leave.
• Ask about equipment. If a walker, hospital bed, or oxygen was ordered, ask who delivers it and when. It is easier if the walker is in the house before your mom is.

Medicare does not cover 24-hour care at home, meal delivery, or housekeeping and personal care when that is the only help you need. That kind of help is called home care, and our guide on home health versus home care explains where to look.

Medicare requires a face-to-face visit with a doctor or nurse practitioner, within 90 days before or 30 days after home health starts. Some doctors make house calls. Ask us, and we will help you find one. That doctor is independent of Comfort Care, and the choice is yours.

What happens next, step by step

1. The order comes to us. The hospital or your doctor sends it to our fax at (818) 301-3175. If you get home and nothing has happened, call us at (818) 579-4012. Families may call first, and we coordinate the order with the doctor.
2. We call you. Your coordinator calls before the first visit. Tell us about the front steps, the dog, or the gate code.
3. The first visit. It usually happens within 24 hours after the doctor or hospital sends the order.
4. Care begins. The nurse and your doctor set the plan of care, including how often visits happen.

What the first visit looks like

Set aside some time for the first visit. Be there if you can. The nurse starts with the medicines. Put every bottle on the kitchen table, including the ones from before the hospital and anything over the counter. The nurse compares each one to the discharge list. Leftover prescriptions and duplicates are common. The nurse flags them for your doctor, and nothing changes until your doctor says so.

Then the nurse checks vital signs, looks at any incision or wound, and asks how you are eating, sleeping, and getting to the bathroom. The nurse watches you stand up from a chair and walk down the hallway. That says a lot about fall risk and whether therapy belongs in the plan.

Before leaving, the nurse writes down what to watch for and who to call. The findings go to your doctor, who signs the plan of care.

What to have ready

• The discharge papers, including the medication list and any wound care instructions.
• Every pill bottle in the house, out on the counter.
• Insurance cards and a photo ID.
• The name and number of the doctor you follow up with.
• A clear path from the front door to the bed and the bathroom. Move the throw rugs and lamp cords for now.

For a printable version, see our coming home from the hospital checklist.

What we promise

You will have one named coordinator who knows your name. The same nurse or therapist comes whenever possible, and if someone else must come, we call first. We call before every visit. We update your doctor, and with your okay, your family. Our team speaks English, Spanish, Armenian, Russian, and Tagalog. If your family speaks another language, call and ask whether we have staff who speak it. If we do not have staff who speak your language, we arrange a free interpreter.

When to call

The first week home is when problems often show up. Call your doctor or nurse if you notice a fever, new or worse pain, redness or drainage around an incision, new swelling in the legs, confusion that was not there before, trouble keeping food or medicine down, or a fall, even a small one. If you are not sure, call. It is better than waiting for the next visit.

Call 911 for chest pain, trouble breathing, heavy bleeding, signs of stroke (a drooping face, weakness on one side, slurred speech), or if someone cannot be woken up.

Cost and who qualifies: with Original Medicare, covered home health is $0 if you qualify, and your doctor decides. See what Medicare covers, who qualifies, and what is not covered.

With Original Medicare, covered home health services cost you $0. Durable medical equipment such as a walker or hospital bed has a 20% coinsurance of the Medicare-approved amount after the Part B deductible. Medicare Advantage plans cover home health too, but they may use their own agency networks and rules. Medicare does not pay for 24-hour care at home or meal delivery. It does not pay for housekeeping or personal care when that is the only care you need. We accept Medicare and private insurance. Read more in Does Medicare cover home health care? and What does homebound mean?