Hospital Discharge Planning Indiana: Questions to Ask and What the Hospital Must Provide

The hospital social worker just told you your parent is being discharged tomorrow morning. You have a stack of papers, a list of facilities you've never heard of, and about 18 hours to figure out what happens next. Most families in Indiana face this moment completely unprepared — and the questions you ask (or don't ask) in the next few hours directly determine whether your parent ends up safe at home or back in the ER within a week.

What Indiana Hospitals Must Provide Before Discharge

Under federal regulations (42 C.F.R. § 482.43), hospitals are required to involve the patient and family caregivers in discharge planning. This isn't optional — it's a condition of Medicare participation. Specifically, the hospital must:

• Evaluate whether the patient needs post-hospital services
• Provide a written discharge plan before the patient leaves
• Supply a list of available home health agencies, SNFs, or rehab facilities — and disclose any financial relationship the hospital has with those providers
• Deliver "An Important Message from Medicare" (IM) at least two calendar days before the planned discharge date

Under Indiana's Lay Caregiver Act (Indiana Code § 16-21-12-7), you also have the right to be formally designated as a "lay caregiver" in the patient's medical record. Once designated, the hospital must provide you with hands-on training for every clinical task you'll need to perform at home — medication administration, wound care, catheter management, feeding tube operation — before discharge occurs.

The Questions You Must Ask the Discharge Planner

Request a formal care conference with the discharge planner, attending physician, and case manager. Bring this list:

Clinical stability questions:

• Is my parent medically stable for discharge, or are test results still pending?
• What specific warning signs should I watch for in the first 72 hours?
• When is the follow-up appointment with the primary care physician?

Medication questions:

• Has a complete medication reconciliation been done comparing pre-hospital medications with the new discharge regimen?
• Are there any drug interactions between old and new medications?
• Which medications require special handling (refrigeration, timing with meals, blood monitoring)?

Care setting questions:

• Does my parent meet the criteria for inpatient rehab (the 3-hour therapy rule), or are they being recommended for a skilled nursing facility?
• If going home: has a home health referral been submitted? Is the agency in-network with my parent's plan?
• Has the physician signed the face-to-face encounter documentation required for home health eligibility?

Indiana-specific questions:

• Is this discharge plan approved by my parent's Indiana PathWays for Aging managed care plan?
• Have you verified that the recommended home health agency and DME supplier are in-network with their PathWays plan (Anthem, Humana, or UnitedHealthcare)?
• Has the LCAR assessment been submitted through the Maximus AssessmentPro portal if my parent needs facility placement?
• Is my parent classified as inpatient or under observation status? (This determines whether they qualify for Medicare-covered SNF rehabilitation.)

Equipment and home safety:

• What durable medical equipment does my parent need at home?
• Has the DME been ordered and when will it be delivered?
• Are there home modifications needed (grab bars, ramp, hospital bed) before discharge is safe?

What to Do if the Plan Feels Unsafe

If you believe your parent isn't ready for discharge — they can't walk safely, their wound care is too complex for home management, or no care plan is in place — you have the legal right to appeal.

Call Commence Health (formerly Livanta), Indiana's designated Quality Improvement Organization, at 888-524-9900 before midnight on the scheduled discharge day. Filing this appeal triggers a mandatory hold: the hospital cannot discharge your parent and Medicare continues covering the stay while Commence Health reviews the case.

You can also request a capacity assessment if you have concerns about your parent's cognitive ability to consent to discharge.

The Care Conference Checklist

Bring these to the meeting:

• Your parent's current medication list (pre-hospitalization)
• Insurance cards (Medicare, Medigap or Medicare Advantage, Medicaid if applicable)
• Your healthcare representative designation or power of attorney documents
• A notepad — care conferences move fast, and details matter
• Your designated lay caregiver's contact information for documentation in the medical record

Document everything discussed. If the discharge planner makes verbal commitments — "we'll have home health set up by Thursday" — ask them to note it in the medical record.

The Indiana Hospital-to-Home Transition Guide includes printable care conference checklists, discharge appeal scripts, and the complete question list formatted for bedside use.

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