Hospital to Home Checklist Elderly Minnesota

What to Have Ready Before Your Parent Leaves the Hospital

Bringing an elderly parent home from the hospital is not just a logistics exercise — it is a medical transition that, done poorly, leads to readmission within 30 days for roughly one in five seniors. The discharge planner will hand you a stack of papers and a pharmacy list. What they will not hand you is a structured plan for the first 72 hours at home.

Here is what actually needs to happen before your parent walks out the door.

Before Discharge Day

Verify admission status. Confirm whether your parent was classified as inpatient or observation. This is especially important for Medicare coverage of a post-discharge skilled nursing facility stay; home health has separate eligibility rules. Ask the hospital case manager directly.

Get the discharge summary. This document lists diagnoses, procedures performed, medications prescribed, follow-up appointments, and activity restrictions. Do not leave the hospital without a printed copy.

Confirm medication reconciliation. Hospital stays routinely change a patient's medication list — new drugs added, dosages adjusted, old medications discontinued. The discharge summary should include a reconciled medication list that matches exactly what your parent will take at home. If anything is unclear, ask the hospitalist or pharmacist before leaving.

Arrange durable medical equipment. If your parent needs a hospital bed, walker, wheelchair, oxygen concentrator, or bedside commode at home, the hospital's social worker should arrange delivery before discharge day. Medicare Part B covers DME when the physician documents medical necessity, though a 20% copay typically applies.

Order home health services. If the physician orders home health nursing or physical therapy, the hospital will refer to a Medicare-certified home health agency. Confirm the agency name, the start date, and the first visit schedule before your parent leaves.

The First 24 Hours at Home

Fill prescriptions immediately. Do not wait until tomorrow. Medication gaps in the first 48 hours after discharge are one of the most common causes of complications and readmission.

Do a home safety walk-through. Check for:

• Clear paths from bedroom to bathroom (no throw rugs, cords, or clutter)
• Grab bars installed near the toilet and in the shower
• Adequate lighting in hallways and stairwells
• A working phone or medical alert device within reach of the bed

Set up the medication schedule. Use a pill organizer and write out the schedule in large print. Note which medications must be taken with food, which cannot be combined, and which are new since the hospital stay.

Confirm the follow-up appointment. The discharge summary should include a primary care follow-up within 7-14 days. If no appointment was scheduled, call your parent's doctor the morning after discharge.

The First Week

Watch for warning signs. Call the physician or go to the ER if your parent experiences new confusion, fever above 101, difficulty breathing, sudden swelling, or worsening pain that the prescribed medications are not controlling.

Request a MnCHOICES assessment if needed. If your parent's functional decline suggests they need ongoing home care services beyond what Medicare home health provides, contact your county's human services office to request a MnCHOICES assessment. The county has 20 business days to complete the assessment, which determines eligibility for Elderly Waiver and other community-based programs.

Get the Full Discharge Navigation System

The Minnesota Hospital Discharge Navigation System includes a 24-item discharge-day readiness checklist, a home safety assessment template, and a medication reconciliation tracker. It covers not just the immediate transition but the administrative steps that follow — MnCHOICES, home care agency selection, and what to do if the home health agency does not show up on the scheduled date.

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