Leaving the Hospital: A Medicare Patient's Guide to the First 30 Days After Discharge
Going home from the hospital is a relief, but the weeks after discharge can be a vulnerable time. Medications change, new symptoms can appear and appointments have to be arranged quickly. Good coordination during this period, often called a "transition of care," is one of the main goals of an accountable care organization. This guide from Advanced Health ACO explains what to expect and how patients and caregivers can prepare.
Before you leave: discharge planning
Hospitals are required to plan for your discharge, and you and your caregiver have a right to take part. Before you leave, make sure you understand:
- Why you were in the hospital and what diagnoses were made.
- Your medication list, including any new medicines, changed doses and medicines you should stop.
- Warning signs that mean you should call your doctor, and those that mean you should call 911.
- Follow-up appointments: who you should see, and how soon.
- Equipment and services you will need at home, such as oxygen, a walker or home health visits.
Ask for a written copy of your discharge instructions. Medicare offers a free "Your Discharge Planning Checklist" on Medicare.gov that many families find helpful.
Your rights if you disagree with the discharge
If you are a hospital inpatient with Medicare, you should receive a notice called "An Important Message from Medicare About Your Rights." It explains your right to appeal if you think you are being discharged too soon. Appeals go to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for your state, and the notice includes its contact information. Our article on your rights as a Medicare patient in an ACO explains that ACO participation never limits these protections.
The first 48 hours at home
- Fill new prescriptions right away and bring all your medicine bottles together in one place.
- Compare the discharge medication list with what you have at home. Ask your pharmacist about any differences.
- Expect a call. Many primary care practices contact patients within a couple of business days of discharge to check on symptoms and medications and to schedule a visit. If you do not hear from your doctor's office, call them.
- Set up your space to prevent falls: clear walkways, add night lights and keep essentials within reach.
The follow-up visit
A prompt follow-up visit with your primary care doctor or specialist is one of the most important steps after a hospital stay. Medicare recognizes this with Transitional Care Management (TCM) services, which include contact with the patient soon after discharge and a face-to-face visit, generally within 7 or 14 days depending on how complex the patient's needs are.
Bring the following to the visit:
- Your discharge paperwork and any test results you were given.
- All of your medications, including over-the-counter drugs and supplements.
- A list of symptoms, questions and changes since you got home.
- Your caregiver, if possible, to help remember instructions.
At the visit, your doctor can confirm the medication list, review hospital results, order any needed tests and arrange referrals or home services.
Medication safety
Medication problems are one of the most common reasons for trouble after discharge. To stay safe:
- Keep one up-to-date list of every medication, dose and time, and share it with every doctor and your pharmacy.
- Do not restart medicines you were told to stop until you have checked with your doctor.
- Use a pill organizer, and ask about blister packs or a medication review if you take many medicines.
- Ask what side effects to watch for with any new medicine.
Know your warning signs
Your discharge instructions should list the symptoms that matter for your condition. For example, a patient with heart failure may be told to weigh themselves daily and to call if their weight rises quickly or swelling increases. Write these signs down and keep them on the refrigerator. For chest pain, severe shortness of breath, fainting, sudden weakness or confusion, call 911.
Support at home
Depending on your needs and coverage, your doctor may order home health care, such as skilled nursing or physical therapy. Some patients also qualify for ongoing services such as Chronic Care Management. Your care team can explain what is available and what Medicare covers in your situation.
How an ACO helps with transitions of care
Care coordination and transitions of care are core services of Advanced Health ACO. Participating practices work to know when their patients are admitted or discharged, follow up promptly, reconcile medications and close gaps in preventive care. See our services for the full list. Practices in the Advanced Health Associates network also offer chronic care management and remote monitoring.
Being part of an ACO does not change your Medicare benefits or your freedom to choose doctors and hospitals. Our earlier guide, What Is an Accountable Care Organization?, explains how ACOs work.
Common questions
Who should I call first after I get home?
Call the doctor or practice named in your discharge instructions, usually your primary care doctor. If you are not sure who is coordinating your care, call your primary care office; they can request your hospital records and arrange follow-up.
Does my ACO doctor get my hospital records automatically?
Hospitals and practices increasingly share discharge information electronically, but it does not always arrive quickly or completely. Bring your discharge papers to your follow-up visit so nothing is missed.
What if I go to a skilled nursing facility first?
The same principles apply when you leave the facility: ask for a medication list and instructions, and schedule a follow-up visit soon after you return home.
Questions?
For questions about your Medicare benefits, call 1-800-MEDICARE (1-800-633-4227). For questions about our ACO, see our FAQ or contact us at 941-412-0026.
This article is general educational information, not medical, legal or insurance advice. Follow the specific instructions from your own doctors. Medicare rules can change; for current information, visit Medicare.gov. In an emergency, call 911.