Hospital to Home Checklist Pennsylvania: Preparing for Your Parent's Discharge

Your parent is being discharged from the hospital to home. The discharge planner says everything is arranged. But "arranged" and "ready" are not the same thing — and the first 48 hours at home are when readmissions happen.

Hospital readmissions within 30 days of discharge cost Medicare billions annually, and for individual families the consequences are worse than financial. A readmission usually means something went wrong at home that should have been caught before or immediately after discharge.

Here is what must be in place before your parent walks through the front door.

Medication Reconciliation

This is the highest-risk item. Your parent may have been on five medications before hospitalization and leave with twelve. Some pre-admission medications may have been changed, paused, or discontinued during the stay.

Before discharge, the attending physician or a pharmacist should review every medication — pre-admission and newly prescribed — and produce a single, clear written list that includes:

• Drug name (generic and brand)
• Dose and frequency
• What it is for (in plain language)
• Whether it is new, changed, or continued from before

Compare this list against the medications currently at home. Dispose of anything that was discontinued. Set up a pill organizer for the first two weeks. If your parent takes more than five daily medications, ask the pharmacist about interaction risks.

Pennsylvania's PACE and PACENET prescription assistance programs help seniors who do not qualify for Medicaid cover medication costs. If your parent is struggling with co-pays, contact the PA Department of Aging (1-800-225-7223) for eligibility screening.

Durable Medical Equipment

If the doctor has ordered equipment — a walker, wheelchair, hospital bed, oxygen concentrator, commode, or patient lift — secure the order and coordinate delivery and setup with the supplier before your parent returns home. Confirm the delivery timing and what training is needed.

The discharge planner is responsible for coordinating the initial DME order, including securing the physician's prescription and arranging delivery with a Medicare-contracted supplier. If delivery has not been confirmed by the morning of discharge, escalate the safety concern and ask the team to document how the gap will be managed.

For patients on Community HealthChoices, the MCO covers DME including "exceptional" items (motorized wheelchairs, specialty beds). For patients on the OPTIONS program, the Area Agency on Aging can assist with basic safety equipment and minor home modifications up to a $5,000 lifetime cap.

Home Safety Assessment

The home your parent left may not be the home they need to return to. After a hospitalization — especially for a fall, stroke, or hip fracture — functional abilities change.

Walk through the house before discharge day and address:

Fall hazards: Remove loose rugs, secure electrical cords, clear pathways between bedroom and bathroom. Install grab bars in the shower and next to the toilet if they are not already there.

Lighting: Every pathway the patient will use — bedroom to bathroom, bedroom to kitchen, front door entry — needs adequate lighting. Install nightlights along hallways and in the bathroom.

Bathroom safety: A shower chair or transfer bench, a handheld showerhead, and grab bars are the basics. If the patient cannot safely step over the tub edge, a walk-in shower conversion may be necessary.

Bedroom setup: If the patient cannot safely use stairs, set up a bedroom on the main floor. A hospital bed may be needed if the patient has difficulty getting in and out of a standard bed.

Emergency access: Clear the path from the front door wide enough for a stretcher. Make sure the patient can reach a phone from the bed and from the main living area.

Caregiver Training

The hospital is required to provide hands-on training to family caregivers for any clinical tasks they will need to perform at home. This includes:

• Wound dressing changes
• Medication administration (especially injections or complex regimens)
• Transfer techniques (bed to wheelchair, wheelchair to toilet)
• Operating medical equipment (oxygen concentrator, feeding pump, patient lift)
• Recognizing warning signs that require immediate medical attention

Ask for this training before discharge day — not during the rushed final hour. Have the caregiver demonstrate each task back to the nurse. Take notes or ask for written instructions.

Follow-Up Appointments

The discharge plan must include scheduled follow-up appointments with the primary care physician and any specialists involved in the hospital care. Schedule the first appointment as directed by the treating team, sooner if the condition is complex.

Confirm transportation. Ask the hospital, insurer, or CHC MCO what transportation benefit applies; coverage depends on the plan and medical need.

The Backup Plan

What happens at 2 AM when the caregiver cannot manage a crisis? Before discharge, establish:

• Who to call first (a specific family member, a 24-hour nurse line, 911)
• When to go to the ER vs. when to call the home health agency
• Where the medication list, insurance cards, and advance directive are kept
• Contact information for the home health agency and the patient's primary physician

The Pennsylvania Hospital Discharge Guide includes a printable hospital-to-home checklist that covers each of these areas, plus a medication reconciliation worksheet and a home safety assessment form.

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