Hospital to Home Checklist Michigan

The First 72 Hours Are Where Things Break Down

Hospital readmission rates are highest in the first three days after discharge. Medication errors, falls, missed follow-up appointments, and delayed equipment delivery are the usual culprits — and they are all preventable with preparation.

If your parent is being discharged from a Michigan hospital and heading home, this checklist covers what needs to happen before they leave the hospital, during the ride home, and in the critical first week.

Before Leaving the Hospital

Get the discharge summary in writing. This should include the diagnosis, procedures performed, test results, and the recommended follow-up care plan. If the discharge planner gives you a verbal summary, ask for the printed version — you will need it for the primary care physician and any home health agencies.

Complete medication reconciliation. Sit down with the discharging nurse and go through every medication your parent was taking before hospitalization alongside every medication prescribed at discharge. You are looking for three things:

• Medications that were stopped during the hospital stay and should not be restarted
• New medications that interact with existing prescriptions
• Dosage changes to existing medications

Mark discontinued medications clearly on the list so nobody refills them by mistake. Medication reconciliation errors can contribute to preventable readmissions in the first week.

Confirm DME delivery. If your parent needs a hospital bed, walker, wheelchair, oxygen concentrator, or wound care supplies at home, verify that the equipment is ordered, the delivery date is confirmed, and someone will be at the house to receive it. Equipment that arrives two days after your parent gets home is useless during the window when falls and complications are most likely.

Schedule follow-up appointments before discharge. The primary care physician and any specialist follow-ups (cardiologist, pulmonologist, wound care) should be scheduled before you leave the hospital — not left as a task for the overwhelmed family caregiver to handle later.

The Ride Home and First Day

Bring the medication list. Tape a copy to the refrigerator door and keep one in the folder with the discharge papers.

Walk through the home before your parent arrives. Remove loose rugs, secure electrical cords, install grab bars in the bathroom if they are not already there, and clear a path wide enough for a walker or wheelchair between the bed, bathroom, and kitchen. The most common post-discharge fall happens when a weakened patient navigates a home layout that was fine before hospitalization but is now an obstacle course.

Set up a medication station. Use a pill organizer loaded for the first week. Set phone alarms for each medication time. If your parent takes more than five medications, a printed daily schedule with large text is more reliable than memory.

The First Week: What to Monitor

Weight. A sudden gain of 2+ pounds in 24 hours can signal fluid retention — a warning sign for heart failure patients that warrants an immediate call to the physician.

Temperature. Fever within the first week may indicate an infection or other complication. Follow the discharge instructions about when to call, and do not wait for the scheduled follow-up appointment if they direct you to call sooner.

Pain and confusion. Some disorientation is normal after a hospital stay, particularly for elderly patients (hospital delirium can persist for days). But worsening confusion, new pain at a surgical or wound site, or inability to keep food down are reasons to call the physician's after-hours line.

Medication side effects. New medications — especially blood thinners, pain medications, and antibiotics — can cause dizziness, nausea, or dangerous drowsiness. Report anything unusual within the first 48 hours rather than waiting to see if it resolves.

Setting Up Longer-Term Home Care in Michigan

If your parent needs ongoing help with bathing, dressing, meals, or mobility beyond what the family can provide, two Michigan programs fund in-home care:

The MDHHS Home Help Program pays a family member (excluding spouses) or registered home care agency to provide hands-on assistance with activities of daily living. Apply through the local county MDHHS office using Form DHS-390, with a medical certification (Form MDHHS-6200) from the patient's physician.

The MI Choice Waiver covers a broader range of services — personal care, homemaker, adult day health, respite, home modifications, and community living supports — for adults who meet Michigan's nursing facility level of care (NFLOC) standard and have countable assets at or below $9,950. Contact your regional Area Agency on Aging to request a clinical assessment.

Medicare also covers skilled home health services (physical therapy, occupational therapy, skilled nursing visits) when ordered by a physician and the patient meets homebound criteria — meaning leaving the home requires considerable and taxing effort.

The Complete Transition Toolkit

The Hospital-to-Home in Michigan guide includes a printable discharge checklist, a medication reconciliation worksheet, a home safety assessment form, and step-by-step instructions for applying to both the Home Help Program and the MI Choice Waiver.

See more Michigan guides →