Hospital Discharge Planning Checklist for Elderly Parents in Illinois

Your parent is in an Illinois hospital and discharge is approaching. The case manager mentions home health, the social worker talks about "next level of care," and a financial counselor appears with Medicaid paperwork. It's overwhelming—but discharge planning follows a predictable structure, and knowing what to ask at each step keeps your parent safe.

What the Discharge Planner Actually Does

The hospital discharge planner (also called case manager or social worker, depending on the facility) is responsible for:

• Assessing your parent's post-discharge care needs
• Coordinating clinical handoffs (medications, equipment, follow-up appointments)
• Arranging the next care setting (home health, SNF, or supportive living)
• Initiating the Choices for Care pre-screening if a facility transfer is planned
• Connecting families with community resources and financial assistance programs
• Ensuring the Illinois CARE Act obligations are met (caregiver training)

They are not your parent's advocate—they work for the hospital, and bed turnover is a metric they're measured on. Be polite, be informed, and document everything.

Questions to Ask at the Care Conference

Request a formal care conference before discharge is finalized. Bring this list:

About the discharge plan:

• What is the expected discharge date?
• What specific care tasks will my parent need at home?
• Has a home health agency been arranged? Which one? When does the first visit happen?
• What durable medical equipment is being ordered? When will it be delivered?
• Who is responsible for scheduling the follow-up physician appointment?

About clinical status:

• Is my parent medically stable? What symptoms should prompt a return to the ER?
• Have all pending test results come back? What did they show?
• Are there new medications? Has the full medication list been reconciled against pre-hospital prescriptions?
• Have potential drug interactions been checked?

About your role:

• What medical tasks am I expected to perform at home? (Wound care, injections, monitoring)
• When will I receive hands-on training under the CARE Act?
• Who can I call after hours if something goes wrong?
• Is there a 24-hour nurse line through the home health agency?

About finances and coverage:

• Was my parent admitted as inpatient or observation? (Critical for SNF coverage)
• If going to a SNF: has the Choices for Care pre-screening been initiated through AssessmentPro?
• If going home: does my parent qualify for the Community Care Program? Has the CCU been contacted?
• Is Medicaid applicable? Has a referral been made to a local Family Community Resource Center?

The Step-by-Step Discharge Checklist

Before Discharge Day

• [ ] Confirm inpatient vs observation status (impacts SNF coverage)
• [ ] Designate yourself as caregiver under the Illinois CARE Act
• [ ] Attend care conference with the discharge planning team
• [ ] Verify home health agency assigned and first visit scheduled
• [ ] Confirm DME ordered and delivery date arranged
• [ ] Receive medication list with instructions (dosage, timing, interactions)
• [ ] Complete CARE Act training on all required aftercare tasks
• [ ] Get names and direct numbers for the discharge planner and home health agency
• [ ] Arrange transportation home (ambulance, medical transport, or personal vehicle)

On Discharge Day

• [ ] Pick up all discharge medications from the hospital pharmacy
• [ ] Receive printed discharge summary (diagnoses, procedures, instructions)
• [ ] Confirm follow-up physician appointment date and time
• [ ] Get a direct phone number for after-hours clinical questions
• [ ] Verify all medical equipment has arrived at home or will arrive same day
• [ ] Review red-flag symptoms that require calling 911 or returning to the ER
• [ ] Sign the Important Message from Medicare acknowledgment (keep your copy)

First 72 Hours at Home

• [ ] Home health nurse initial assessment visit (typically within 24-48 hours)
• [ ] Reconcile all medications—compare hospital discharge list to what's in the medicine cabinet
• [ ] Set up medication management system (pill organizer, alarm reminders)
• [ ] Perform initial home safety walkthrough (grab bars, clear pathways, adequate lighting)
• [ ] Attend follow-up physician appointment within 7 days
• [ ] Contact CCU for Community Care Program screening if ongoing support needed
• [ ] Begin tracking symptoms and any changes from baseline

Illinois-Specific Resources

• Illinois Senior Helpline: 800-252-8966 (connects to your regional Area Agency on Aging and CCU)
• Acentra Health QIO: 888-317-0751 (discharge appeals and advocacy)
• Illinois Department on Aging: Administers the Community Care Program and CCU network
• Family Community Resource Centers: Local DHS offices for Medicaid applications

When Discharge Planning Goes Wrong

If the hospital is rushing discharge without completing these steps:

• Ask to speak with the patient advocate
• Document gaps in writing (email creates a timestamp)
• Request Immediate Advocacy through Acentra Health for communication mediation
• File a formal appeal if you believe the discharge is premature or unsafe

The Hospital-to-Home Illinois toolkit provides this full checklist in printable format, plus the discharge appeal protocol, SNF admission worksheet, and first-72-hours monitoring guide—everything you need to manage this transition safely.

See more Illinois guides →