Coming Home From Hospital: What the First Two Weeks Really Need

The call usually comes on a Tuesday. Your mother is doing well, she's ready to go home, can somebody pick her up Thursday morning.

Three days ago she couldn't stand up unassisted. Nobody has explained how she's going to manage the stairs, or who's going to be there when she wakes at night, or what happens if she forgets she isn't supposed to put weight on that hip.

Here's what families need to know, in the order they need it.

You're allowed to say the date is too soon

Most families don't know this, and hospitals rarely volunteer it.

If your loved one is a hospital inpatient on Original Medicare, the hospital must give them a notice called an Important Message from Medicare. It's signed within two days of admission, and a copy is usually given again shortly before discharge.

That notice explains how to request a fast appeal if you believe the discharge is too early. The appeal goes to a Quality Improvement Organization, an independent body of doctors and health care experts, and the number is printed on the notice itself.

The deadline matters. The appeal has to be requested no later than the day of the planned discharge, before leaving the hospital. The organization should decide within about a day of getting what it needs. If the appeal is requested on time, the hospital can't charge for the stay through noon of the day after the decision, apart from normal coinsurance or deductibles, even if the appeal doesn't succeed.

This isn't a way to keep somebody in the hospital indefinitely, and it isn't an argument with the staff. It's a formal second opinion on timing, and it exists because discharge dates are sometimes driven by things other than whether a person is ready.

If the extra day is what you need to get care arranged at home, it helps to know the option exists.

What Medicare covers once she's home, and what it doesn't

This is where most families get surprised.

Medicare may cover part time clinical care and therapy at home, if a doctor orders it and the person is homebound, which is common after a hospital stay. A visiting clinician might check a wound, manage an IV, or run physical therapy sessions.

It's short term by design. It ends when the clinical goal is met, often in a few weeks.

That's a different service, delivered by a different kind of licensed agency, and Golden Years doesn't provide it. Our caregivers help with daily living, not clinical care.

What Medicare doesn't cover is the rest of it. Somebody there in the morning to help her wash and dress. Meals. The drive to the follow-up appointment. Somebody in the house at three in the morning when she decides to get up on her own.

That gap is where most families end up, and it usually arrives as a surprise about four days after discharge.

What actually goes wrong in the first two weeks

Not dramatic things. Small ones, stacking up.

The medication changes nobody absorbed. People come home from the hospital on a different list from the one they went in with. Doses change, new things are added, old things stop. Everyone is given a printed sheet during a conversation they were too tired to follow, and nobody reads it again until something goes wrong.

Getting up at night. Plenty of falls at home happen on the way to the bathroom in the dark, and after a hospital stay somebody is weaker, possibly on something that makes them drowsy, and still behaving as though they're as steady as they were a month ago.

Not eating. Appetite often doesn't come back for a week or two. Shopping hasn't been done, the fridge is empty, and cooking for one when you're exhausted doesn't happen. People lose ground quickly this way.

The follow-up appointment. Scheduled ten days out, written on a piece of paper, and missed because nobody could drive.

The family caregiver running on nothing. A daughter taking a week off work, sleeping on the couch, doing everything, and reaching day six in no state to make good decisions. Our article on what a real break does for a family caregiver is worth reading before that point arrives.

How much help, realistically

More than families expect for the first two weeks, and less after that.

Those two weeks shape a lot of what follows. Somebody there in the mornings for washing, dressing and breakfast, with medication reminders built into the routine, which is what personal home care covers. Somebody doing the shopping and making sure meals actually happen. Somebody driving to the follow-up.

Nights are the real question. If the discharge involved a fall, a hip, a stroke, or any confusion at all, overnight is where 24 hour home care earns its place, because somebody is awake rather than asleep down the hall. Overnight is when a lot of first-week trouble starts.

After the first two weeks most people step down to a few hours a day, or a few days a week. That's a normal shape, and it's sensible to plan for it from the start rather than committing to one level indefinitely.

If dementia is in the picture as well, a hospital stay often leaves somebody noticeably more confused than they were before, and that can take weeks to settle. Dementia care at home during that period is less about tasks and more about keeping the day recognizable while they find their footing again.

Arranging it before she comes home

The practical answer is to start before the discharge date rather than after it.

Ask the discharge planner what clinical care at home has been ordered and for how long. Then work out what isn't covered by it, which is most of the daily business of living.

A free in-home assessment can happen while your loved one is still in the hospital. Somebody comes to the house, looks at the stairs and the bathroom and the lighting, and tells you what the first two weeks will actually need. There's nothing to sign.

Call (916) 333-0383 in Greater Sacramento or (619) 430-4443 in San Diego County.

This article is general information for families and is not medical, legal, financial or insurance advice. Medicare rules and coverage may change. Check your own situation with the hospital, your plan or a licensed advisor.

How Golden Years helps

Golden Years is family owned and has cared for California families since 1996. Our caregivers are our own W-2 employees, and a care manager oversees every care plan, from the busy first two weeks to the lighter ones after.

Start with a free in-home assessment before the discharge date if you can. We'll look at what she'll need at home and tell you whether a few hours each morning, dementia care, Alzheimer's care at home or 24 hour home care is the right fit for the first two weeks. Licensed Home Care Organization #344700040.