Hospital-to-Home Checklist for Elderly Parents in Massachusetts

The discharge planner says your parent is going home Thursday. That gives you 48 hours to transform a house into a recovery environment, coordinate services from three different agencies, and learn how to change a wound dressing — all while managing your own job and family.

This checklist covers every step of the hospital-to-home transition in Massachusetts, from the moment discharge is announced to the first month at home.

Week Before Discharge (or As Soon As Announced)

Legal and advocacy steps:

• [ ] Confirm you are recorded as the designated caregiver under the CARE Act (MGL c. 111, § 236)
• [ ] Review the written discharge plan — it must include provider names, contact information, service schedules, and medication instructions (required under 105 CMR 130.343)
• [ ] If you disagree with the discharge timing, notify the professional staff and request a meeting with the discharge coordinator and attending physician
• [ ] For Medicare patients: review "An Important Message from Medicare" — understand your appeal rights if you believe discharge is premature

Service coordination:

• [ ] Confirm which home health agency has been selected and when the first visit is scheduled
• [ ] Contact your local ASAP (Aging Services Access Point) to begin a home care assessment
• [ ] Ask the discharge planner about the State Home Care Program or Frail Elder Waiver if your parent needs ongoing non-medical support
• [ ] Schedule a follow-up appointment with the primary care physician within 7 days of discharge

Equipment and supplies:

• [ ] Confirm all Durable Medical Equipment (DME) has been ordered under Medicare Part B — hospital bed, wheelchair, walker, shower chair, bedside commode
• [ ] Verify delivery date and confirm it aligns with the discharge date
• [ ] Request prescriptions for any needed DME that has not yet been ordered

24 Hours Before Discharge

Medication preparation:

• [ ] Get the final discharge medication list from the attending physician or pharmacist
• [ ] Compare it line-by-line against pre-hospitalization medications — document every change
• [ ] Confirm all prescriptions have been transmitted to the pharmacy
• [ ] Pick up filled prescriptions if the pharmacy can process them before discharge

CARE Act training:

• [ ] Request hands-on instruction for every medical task: wound care, injections, catheter management, safe transfers, medication administration
• [ ] If the hospital has not provided this training, tell the discharge planner — they are legally required to deliver it before discharge

Home preparation:

• [ ] Remove trip hazards from pathways (rugs, clutter, cords)
• [ ] Install grab bars in the bathroom and along stairways
• [ ] Set up the recovery space: bed positioned for easy access, nightstand stocked with water, phone, and medication
• [ ] Ensure lighting is adequate on all pathways from bedroom to bathroom
• [ ] Stock the kitchen with easy-to-prepare meals for the first week

Discharge Day

• [ ] Collect all discharge paperwork, including the written care plan, medication list, and follow-up appointment details
• [ ] Verify DME has arrived at home (call a family member or neighbor to confirm)
• [ ] Arrange transportation — medical transport if your parent requires a stretcher or wheelchair-accessible vehicle
• [ ] Ask the nurse for direct contact numbers for the care team if questions arise after hours
• [ ] Confirm the home health agency has the correct home address and phone number

First 72 Hours at Home

• [ ] Complete the medication reconciliation — set up the pill organizer, post the schedule, set reminders
• [ ] Conduct a home safety walk-through with your parent — identify any obstacles or hazards you missed
• [ ] Confirm the home health nurse has made the first visit (should occur within 48 hours)
• [ ] Monitor for readmission warning signs: new confusion, fever over 100.4°F, falls, worsening pain, inability to keep food or medications down

First Two Weeks

• [ ] Attend the follow-up primary care appointment
• [ ] Track daily progress: mobility, appetite, sleep quality, pain levels, medication adherence
• [ ] If your parent is not improving or is declining, contact the primary care physician and the home health agency
• [ ] Begin the ASAP intake process for longer-term home care services if not already started
• [ ] If you are the sole caregiver, contact the ASAP about respite care options

Get the Complete Printable Transition Toolkit

The Massachusetts Hospital-to-Home Transition Toolkit includes this entire checklist as a printable PDF, plus the CARE Act demand letter, the Acentra Health appeal script, and the MassHealth eligibility worksheet — designed to guide Massachusetts families through every step of the hospital-to-home transition.

See more Massachusetts guides →