Hospital to Home Transition Checklist Missouri

The 72 Hours Before Discharge

The transition from a Missouri hospital to home is not a single moment — it is a 72-hour process that starts the day the discharge planner first mentions a target date. Families who wait until the morning of discharge to start preparing face gaps in medication, missing equipment, and no care coverage. Here is what to arrange before your parent leaves the hospital.

Medication Reconciliation

Request a complete, updated medication list from the hospital's discharge summary before your parent leaves. This list must include every medication prescribed during the hospital stay — including new drugs — alongside the dosage, frequency, and reason for each one.

Cross-reference this list with the medications physically present in your parent's home. Look for:

• Duplications — the hospital may have prescribed a brand-name version of a generic your parent already takes
• Dangerous interactions — new medications can conflict with existing prescriptions your parent's primary care physician ordered months ago
• Medications that require refrigeration or special handling — make sure these are available at home before discharge

If anything is unclear, ask the hospital pharmacist (not just the nurse) to review the full list before discharge.

Durable Medical Equipment

The hospital case manager must coordinate delivery of any required medical equipment before the patient arrives home. Common items include:

• Hospital bed with adjustable head and foot positioning
• Bedside commode or raised toilet seat
• Shower chair or transfer bench
• Wheelchair or rolling walker
• Oxygen concentrator and backup portable tanks
• Patient lift for transfers (if the patient cannot bear weight)

Medicare Part B covers DME when ordered by a physician and supplied by a Medicare-certified supplier. The equipment must be medically necessary and appropriate for home use. Confirm with the supplier that delivery is scheduled for the day before discharge — not the day after.

Home Safety Modifications

Walk through your parent's home with fresh eyes before they return. A hospital stay often reveals functional limitations that were not apparent before admission:

• Bathroom: Install grab bars near the toilet and inside the shower. Remove loose bath mats. Consider a handheld showerhead.
• Bedroom: Clear a path from bed to bathroom wide enough for a walker. Move the bed to a ground-floor room if the parent cannot safely navigate stairs.
• Kitchen: Place frequently used items at counter height. Remove area rugs and extension cords from walking paths.
• Entryway: Ensure exterior walkways are well-lit. Add a handrail to any steps between the car and the front door.

Missouri's Home Modification Program through the Division of Senior and Disability Services may cover some of these modifications for Medicaid-eligible individuals.

Arranging Post-Discharge Care Services

Medicare Home Health

If your parent is homebound and needs skilled nursing visits, physical therapy, or occupational therapy at home, the attending hospital physician must write an order for Medicare-certified home health before discharge. Medicare Part A covers these services with no copay, but the patient must meet the homebound definition — leaving home requires considerable effort, and absences are infrequent and short in duration.

Ask the discharge planner which home health agency will be assigned. You have the right to choose from any Medicare-certified agency in your area, not just the one the hospital suggests.

Missouri Medicaid Home Care

If your parent needs daily personal care assistance — bathing, dressing, meal preparation, toileting — that goes beyond what Medicare home health covers, contact the Division of Senior and Disability Services (DSDS) at 1-866-835-3505 to initiate a referral for Home and Community-Based Services.

DSDS will schedule an in-home assessment using the InterRAI HC tool. The patient must score at least 18 points and meet MO HealthNet financial eligibility to qualify. Because this process takes time, start the referral while your parent is still in the hospital — do not wait until they are home and the care gap is already open.

Follow-Up Medical Appointments

Schedule a face-to-face appointment with your parent's primary care physician within 7 to 14 days of discharge. This visit is critical for reviewing the hospital's medication changes, assessing recovery progress, and catching early signs of complications that could lead to readmission.

The Missouri Hospital Discharge Guide provides the complete transition checklist with specific timelines, equipment delivery tracking forms, and the DSDS referral process to ensure no critical step is missed during the move from hospital to home.

See more Missouri guides →