Hospital Discharge Planning for Elderly Parents: Questions to Ask in Wisconsin

The discharge planner just told you your parent is going home — or to a facility — in 48 hours. You have a narrow window to ensure the transition plan is safe, complete, and doesn't set your parent up for a readmission. Nearly one in five Medicare patients over 65 is readmitted within 30 days, and poor discharge planning is consistently cited as a leading cause.

Here are the specific questions to ask, organized by the decision points that matter most.

Before You Leave the Meeting

"Is my parent classified as inpatient or observation?" This determines whether Medicare will cover skilled nursing facility rehabilitation afterward. If the answer is observation, ask what clinical criteria would support reclassification to inpatient status.

"What level of care does my parent need after discharge?" The discharge planner should have a clear answer: home with self-care, home with home health services, short-term rehabilitation at a skilled nursing facility, or long-term placement. If they're vague, press for specifics.

"Who ordered the home health referral, and when does the first visit happen?" Home health visits should begin within 48 hours of discharge. Get the agency name, the first visit date, and the direct phone number. If no home health was ordered but your parent needs skilled care at home, ask why.

Medication Questions

"Can you walk me through the medication reconciliation?" Your parent was taking medications before admission. The hospital added or changed medications during the stay. The discharge prescription list should reconcile both — and someone needs to explain every change, every new drug, and every interaction risk.

"Which medications are new, which were stopped, and why?" Don't accept a printed discharge summary without this conversation. Medication errors during care transitions are one of the most common and preventable safety issues.

"Who will fill these prescriptions before my parent gets home?" This seems obvious, but it's frequently missed. If your parent needs a new medication that requires a specialty pharmacy, prior authorization, or isn't in stock at the local pharmacy, a gap of even one day can cause problems.

Equipment and Home Safety

"What durable medical equipment has been ordered?" Hospital beds, walkers, wheelchairs, shower chairs, oxygen concentrators, bedside commodes — if your parent needs any of these, they must be delivered and set up before discharge. Ask for the DME supplier name, delivery date, and Medicare coverage confirmation.

"Has anyone assessed whether my parent's home is safe for their current condition?" This is the question discharge planners often skip. A parent who could navigate stairs before the hospital stay may not be able to now. A bathroom without grab bars becomes a fall risk. If no home safety assessment has been done, request one from the occupational therapist before discharge.

"Does my parent need 24-hour supervision at home?" If the answer is yes, Medicare home health won't cover it — they provide intermittent visits, not round-the-clock care. You'll need to arrange either family coverage, private-pay home care aides, or consider whether home discharge is actually appropriate.

Follow-Up Care

"When is the first follow-up appointment, and with whom?" Best practice is a physician follow-up within 7 days of discharge. If the discharge planner says "follow up with your primary care doctor" without scheduling the appointment, that follow-up often doesn't happen. Ask them to schedule it before discharge.

"What symptoms should prompt an immediate return to the ER?" Get this in writing, specific to your parent's condition. Generic "seek medical attention if symptoms worsen" is not actionable. You need specific warning signs: temperature above X, wound drainage changing color, sudden confusion, inability to keep medications down.

"Who do I call at night or on weekends if something goes wrong?" The discharge planner's number won't help at 2 AM on Saturday. You need the home health agency's after-hours line, the nursing triage line, and clarity on when to call 911 versus when to call the on-call nurse.

Transportation

"How is my parent getting from here to the next care setting?" If your parent can sit upright and tolerate a car ride, family transport may work. If they need a stretcher, wheelchair transport, or medical monitoring during transfer, the discharge planner should arrange non-emergency medical transportation. Ask who's paying — Medicare covers medically necessary ambulance transport, but not a wheelchair van.

What If You're Not Ready

You have the right to say the discharge plan isn't safe. If the plan has gaps — no DME delivery confirmed, no home health scheduled, no follow-up appointment made — document the gaps in writing and give the list to the discharge planner. If the hospital pushes forward anyway, you can file an expedited appeal with Livanta LLC (Wisconsin's designated QIO) to pause the discharge while the plan is reviewed.

The Complete Discharge Toolkit

These questions are the starting point. The Wisconsin Hospital Discharge Guide includes a complete discharge checklist, pre-written questions for every care setting, and a day-by-day timeline for the first week after your parent comes home — covering everything from medication reconciliation to the first home health visit.

See more Wisconsin guides →