Home Care After a Hip Fracture or Stroke in Illinois

The 24-Hour Window That Changes Everything

Your parent is in an Illinois hospital after a hip fracture or stroke, and the discharge planner just told you they cannot go home safely without daily assistance. Under Illinois law, any senior age 60 or older being considered for nursing home admission must undergo a mandatory Choices for Care screening — a requirement designed to ensure families know about home-based alternatives before a facility placement happens.

That screening is your opening to bring your parent home instead.

Two Types of Care Your Parent Will Need

After a hip fracture or stroke, recovery requires two distinct categories of care that operate under completely different payment and licensing systems:

Skilled home health care. Physical therapy, occupational therapy, speech therapy (critical after stroke), and skilled nursing visits ordered by the attending physician. These may be covered by Medicare for short-term home health when the applicable Medicare requirements are met. A licensed Home Health Agency delivers these services under the physician's plan of care.

Nonmedical home care. Daily assistance with bathing, dressing, meal preparation, medication reminders, and transferring safely between bed, wheelchair, and toilet. Medicare does not cover this. Your options are private pay (averaging $30 to $35 per hour in Illinois), long-term care insurance, or state-subsidized programs — the Community Care Program (CCP) or the Medicaid Persons Who Are Elderly waiver.

The gap between what Medicare covers and what your parent actually needs is where most families get stuck. A physical therapist visits three times a week for 45 minutes. Your parent needs someone there every morning to help them get out of bed safely.

Getting Home Care Services Started Before Discharge

Contact the Care Coordination Unit immediately. While your parent is still hospitalized, call the Senior HelpLine at 1-800-252-8966 to identify the CCU serving your parent's home ZIP code. Explain the pending discharge and ask how quickly intake and the Determination of Need (DON) assessment can be arranged.

Ask the hospital social worker for a referral. The discharge planning team can help connect the family with the CCU and a Medicare-certified Home Health Agency. Ask the agency to confirm when skilled therapy can begin while the CCU processes intake for longer-term nonmedical home care.

Verify the DON score. Hip fracture and stroke can create impairments relevant to the DON, but neither diagnosis guarantees the 29-point minimum required for CCP or waiver eligibility. The assessment considers the parent's actual functional limitations and unmet needs. If your parent has a dementia or organic brain syndrome diagnosis, a 10-point cognitive adjustment is automatically added to the impairment score.

The Rehabilitation Timeline

The first 90 days after a hip fracture or stroke are the most intensive recovery window:

Weeks 1–3. Skilled nursing visits for wound care (hip fracture surgical site), medication management, and fall-risk assessment. Physical therapy begins immediately — range of motion, weight-bearing progression, and transfer training.

Weeks 4–8. PT and OT sessions focus on functional independence — stair climbing, kitchen safety, and bathroom transfers. If your parent had a stroke, speech-language pathology addresses swallowing difficulties and communication recovery. Continued Medicare coverage depends on the applicable home-health requirements and the physician's plan of care.

Months 3–6. Medicare-covered skilled services may end when the applicable coverage requirements are no longer met. Nonmedical home care may still be needed for bathing, dressing, meal preparation, and household tasks.

Preventing Readmission and Falls

Illinois hospitals are penalized for 30-day readmissions, and hip fracture patients face a 20% to 30% readmission rate nationally. The highest risks in the first month:

• Falls during transfers (bathroom, bed, car)
• Medication errors when managing new prescriptions at home
• Dehydration and poor nutrition when the parent cannot prepare meals independently
• Blood clots from immobility

A structured home care plan can combine homemaker services, safety modifications, and a medical alert pendant through the state's Emergency Home Response Service. EHRS is provided at no out-of-pocket cost to eligible CCP participants; homemaker cost-sharing depends on the participant's income and care plan.

What to Do This Week

The critical path is parallel, not sequential. While your parent is recovering in the hospital or a short-term rehabilitation facility:

1. Call the Senior HelpLine (1-800-252-8966) to start the CCU intake process
2. Ask the discharge planner to arrange Medicare home health services and confirm the expected start date
3. Gather five years of bank statements and income documentation for the Medicaid or CCP financial review
4. Ask the CCU what home-safety assessment or modification referrals are available as part of the care plan
5. Install basic safety modifications (grab bars, raised toilet seat, shower bench) before the homecoming

The Illinois home care guide provides the complete discharge-to-home-care timeline, the DON assessment preparation checklist, and document-gathering worksheets designed to get services authorized as quickly as possible after a hospital crisis.

See more Illinois guides →