Hospital to Home Checklist District of Columbia

48 Hours Before Discharge

The discharge planner at MedStar Washington Hospital Center, GW Hospital, or whichever DC facility your parent is in should be coordinating all of this — but families who leave it entirely to the hospital risk gaps. Here's what to confirm before anyone signs the discharge paperwork.

Medical equipment. Has the physician ordered the durable medical equipment your parent needs — hospital bed, wheelchair, oxygen concentrator, walker? Verify that the supplier has the order and confirm a delivery date. Medicare Part B covers 80% of approved DME; the 20% co-insurance applies unless your parent has supplemental coverage.

Home health referral. If the discharge plan includes skilled nursing visits or therapy at home, the hospital social worker must initiate the referral before discharge. A signed physician order and a documented care plan are required. Ask which home health agency was selected and whether they accept your parent's insurance — especially if your parent is enrolled in AmeriHealth Caritas DC or another managed care plan.

Medication list. Get the complete, reconciled medication list from the hospital pharmacist. Compare it against your parent's pre-hospital prescriptions. Flag any duplicates (brand name vs. generic equivalents prescribed in the hospital), discontinued medications, and new prescriptions.

24 Hours Before Discharge

Home safety assessment. Walk through the home with the discharge instructions in hand. Can your parent get to the bathroom with a walker? Are there throw rugs that create fall hazards? Is there a clear path from the bedroom to the kitchen? If your parent needs a ramp or grab bars, ask the social worker about emergency home modifications — the EPD Waiver covers some home safety modifications for eligible beneficiaries.

Caregiver training. Under the DC CARE Act, the hospital must identify you as the designated family caregiver and provide written instructions on the medical tasks you'll perform at home. If you're expected to manage wound care, catheter maintenance, medication injections, or feeding tube care, insist on hands-on training with the nurse before discharge day.

Pharmacy coordination. Call your parent's pharmacy to ensure all discharge prescriptions will be ready for pickup on discharge day. If any medications require prior authorization from the insurance plan, start that process now — a gap in medication access during the first 48 hours at home is one of the leading causes of hospital readmission.

Discharge Day

Get the discharge summary. This document includes the hospital diagnosis, procedures performed, test results, and the care plan going forward. You'll need it for the follow-up physician appointment and any specialists your parent will see.

Confirm transport. If your parent can't safely ride in a standard car, arrange medical transport in advance. DC Medicaid covers non-emergency medical transportation for eligible beneficiaries through the managed care plan.

Collect all personal belongings. Check bedside drawers, the closet, and the bathroom. Dentures, hearing aids, and glasses get left behind frequently.

The First 7 Days at Home

Book the follow-up appointment within 7 to 14 days. This is the single most effective step to prevent readmission. The primary care physician needs to review the hospital discharge summary, reconcile medications, and assess how recovery is progressing.

Monitor for warning signs. Watch for fever, increased pain, confusion, difficulty breathing, or signs of infection at surgical sites. If any of these appear, contact the physician immediately rather than waiting for the scheduled follow-up.

Start the medication reconciliation log. Track what your parent is actually taking, when, and whether they're experiencing side effects. Bring this log to the follow-up appointment.

Assess whether the care plan is working. If the home health aide hours aren't sufficient, the equipment isn't adequate, or your parent's condition is declining, contact the discharge planner or the DC Healthcare Ombudsman for assistance.

When the Transition Needs More Support

A checklist covers the operational basics, but hospital-to-home transitions in DC involve layers of coverage rules, appeal deadlines, and benefit programs that a checklist can't fully address. The DC Hospital-to-Home Transition Toolkit provides the complete system — from discharge safety checklists to the EPD Waiver application roadmap and Medicaid spend-down calculator.

See more District of Columbia guides →