Care Transition Checklist Virginia: Hospital-to-Home Planning Timeline

The 48-Hour Pre-Discharge Timeline

Hospital discharge in Virginia moves fast once the clinical team decides your parent is ready. The window between the discharge decision and the actual discharge can be as short as a few hours. Working backwards from that moment, here is what needs to happen — and when — to avoid the gaps that lead to readmissions, coverage denials, and unsafe transitions.

Two Days Before Discharge (or Upon Admission, Whichever Is Earlier)

Verify admission status. Confirm whether your parent is classified as an inpatient or an outpatient under observation status. This single fact determines Medicare SNF eligibility, appeal rights, and your entire financial trajectory. Ask the attending physician or the nurse assigned to your parent's care.

File your caregiver designation. If your parent is admitted as an inpatient, the Virginia Caregiver Aftercare Act (Code of Virginia § 32.1-137.03) lets your parent or legal guardian designate you or another individual as the post-discharge caregiver. The hospital must record this in the medical chart, notify the designated caregiver before discharge, provide the written discharge plan, and consult with that person about their ability to perform the required care.

Locate legal documents. If your parent has a durable financial power of attorney and an advance medical directive, bring copies to the hospital. If they do not — and your parent still has cognitive capacity — this is the time to execute them. If your parent lacks capacity and has no documents, you may need guardianship, which takes weeks, not days.

Request the LTSS screening. If your parent may need long-term custodial care after discharge (not just short-term rehab), ask the discharge planner to initiate the Medicaid LTSS screening. This must be completed and entered into the eMLS portal with "Accepted Authorized" status before a nursing facility can accept a Medicaid-funded admission without triggering a six-month reimbursement penalty.

One Day Before Discharge

Review the discharge plan in detail. The discharge planner should present a written plan covering: where your parent is going (home, SNF, rehab, assisted living), what clinical care is needed there, which medications are prescribed, when follow-up appointments are scheduled, and what equipment is required.

Conduct medication reconciliation. Request a side-by-side comparison of pre-admission medications against the discharge medication list. New drugs, changed dosages, and discontinued medications should all be explained. Fill prescriptions before leaving if the hospital pharmacy or a partner pharmacy can process them.

Confirm the Important Message from Medicare. Verify that your parent received Form CMS-10065. If you disagree with the discharge, you must contact Commence Health at 888-396-4646 by midnight on the discharge day to file an expedited appeal.

Confirm post-acute care is lined up. If your parent is going to a SNF: Is the PASRR screening complete? Is the facility in-network with your parent's Cardinal Care MCO? If your parent is going home: Is home health ordered? Is durable medical equipment scheduled for delivery? Is the home physically safe (grab bars, clear pathways, bed rail if needed)?

Discharge Day

Get the discharge summary in writing. This document contains the clinical narrative of the hospital stay, all diagnoses, procedures performed, and the care plan going forward. Your parent's primary care physician needs this for the follow-up visit. The SNF or home health agency needs it to continue care.

Bring medications home. If new prescriptions were not filled the day before, fill them on the way home or arrange same-day delivery. Do not let a single day pass without the new medications.

Schedule follow-up appointments. If the discharge planner did not schedule these, call the primary care physician and any relevant specialists today. The first follow-up should typically happen within 7 to 14 days, or on the schedule the treating clinician recommends.

Set up the home care environment. If your parent is returning home, confirm that durable medical equipment has arrived, the bed or recovery area is set up, and someone will be present for at least the first 24 hours. If home health was ordered, confirm the agency has the discharge summary and knows the start date.

After Discharge: The First Week

Day 1-2: Monitor for the discharge warning signs listed in the paperwork. Weigh your parent daily if the discharge was cardiac-related. Check medication compliance.

Day 3-5: The home health nurse should make the first visit. They will assess vital signs, review medications, check any wounds or surgical sites, and flag concerns to the ordering physician.

Day 5-7: Attend the primary care follow-up visit. Bring the discharge summary, the current medication list, and any observations from the first week (changes in appetite, mobility, cognition, pain, or mood).

The Virginia Hospital-to-Home Transition Guide provides a printable version of this timeline with the forms, phone numbers, and clinical checklists for each step — designed to be used in real time during the hospital stay, not just read in advance.

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