By Memphis Senior Advisor Care Team · September 23, 2026
Get the discharge plan and medication list in writing before leaving, confirm the first home health visit, book the follow-up appointment within one to two weeks, fix fall hazards, and cover nights for the first week. If the plan is not working by day seven, escalate.
Before leaving the hospital
Whether your parent is leaving Methodist University, Baptist Memorial in East Memphis, Saint Francis on Park Avenue, Regional One or a suburban hospital, the last hours before discharge are the most valuable. Ask the case manager for the discharge summary, the full medication list with what changed and why, the follow-up appointments, and the name of any home health agency or equipment company that accepted the referral.
Ask one more question that changes everything financially: was your parent admitted as an inpatient, and for how many days? Medicare's skilled nursing benefit requires a qualifying inpatient stay of at least three days, and observation days do not count. If home was chosen over a rehab stay because of that rule, it is worth knowing now.
A day-by-day plan
The table is a starting point; adjust it to your parent's needs and the instructions from the hospital.
| When | What to do |
|---|---|
| Day 1 (before leaving) | Confirm inpatient vs. observation status; get the discharge plan and medication list in writing |
| Day 1 | Fill new prescriptions; compare against the old list; remove discontinued pills from the house |
| Day 2 | Confirm the home health agency's first nursing visit date if home health was ordered |
| Days 2-3 | Schedule the follow-up physician visit (usually within 7-14 days) |
| Days 3-4 | Walk the house for fall risks: rugs, lighting, bathroom grab bars, bed height |
| Days 4-5 | Decide who covers nights for the first week; arrange paid help if needed |
| Day 7 | Review: is the plan working? If not, call the physician and the Aging Commission of the Mid-South |
Medications deserve the most attention. New prescriptions often replace old ones with different names, and the old bottles are still in the cabinet. Put the new list on the refrigerator, set up a weekly pill organizer, and ask the pharmacist to review the list for duplicates.
Home health: what to expect in Memphis
If the physician ordered home health and your parent is homebound, Medicare pays for intermittent skilled nursing and therapy visits from a Medicare-certified agency. Tennessee's Health Facilities Commission lists 29 licensed home health agencies with offices in Shelby, Fayette and Tipton counties, although some focus on infusion or pediatric care. The agency should call to schedule the first visit within a day or two of discharge; if it does not, call the agency and the discharging physician's office.
Home health does not include hourly aides for bathing, meals or supervision. If your parent needs that help, arrange it privately or ask the Aging Commission of the Mid-South at (901) 222-4111 about OPTIONS for Community Living or TennCare CHOICES.
When home is not working
Signs that the plan is failing usually show up by the end of the first week: missed doses, a fall or near-fall, confusion that is worse than in the hospital, not eating, or a family caregiver who has not slept. Call the physician first. If short-term skilled care is needed, a nursing home rehab stay may still be possible under Medicare with a new qualifying admission, or under a Medicare Advantage plan's rules.
If the week shows that your parent cannot be safe at home even with help, start looking at licensed assisted-care living facilities or nursing homes now, while there is time to compare records. Every licensed facility in the three counties is in our directory, with state survey dates, disciplinary records and, for nursing homes, CMS ratings.
Medication reconciliation, step by step
Most problems in the first week come from medications. Lay every bottle in the house on the kitchen table, including vitamins and over-the-counter pills, next to the discharge list. Put aside anything the discharge list says to stop. Check for the same drug under brand and generic names. Confirm doses that changed, especially blood thinners, diabetes medications, diuretics and blood pressure pills, which can cause falls or dangerous swings when doubled or skipped.
Then decide who gives the medications. If your parent managed their own before the hospital, watch them do it for a few days. If they cannot, a weekly organizer filled by a family member, a pharmacy that packages doses by time of day, or a home care aide's reminders can bridge the gap. If none of those is enough, that is important information for the bigger decision about where your parent should live.
Night coverage and the first follow-up visit
The first nights home are often the hardest: unfamiliar medications, weakness after bed rest, and confusion that can worsen after dark. Plan for someone to stay overnight for at least the first few nights, or arrange paid overnight help. A bedside commode and a clear, lit path to the bathroom reduce the riskiest trips.
Bring the discharge summary, the medication list and a written list of questions to the first follow-up visit. Ask whether any test results were pending at discharge, whether therapy should continue, and what symptoms should prompt a call or a return to the emergency department.
Paying for the gaps
Medicare home health covers skilled visits, not the hours in between. For a short period, families often pay a home care agency privately; CareScout's 2025 Tennessee median is about $31 an hour. For longer needs, OPTIONS for Community Living and TennCare CHOICES can help eligible residents, and VA Aid and Attendance can help veterans and surviving spouses. If a nursing home rehab stay follows a qualifying three-day inpatient admission, Medicare Part A covers up to 100 days while daily skilled care is needed, with no coinsurance for the first 20 days.
Who to call when
Keep a short list on the refrigerator: the physician's office for new symptoms and medication questions, the home health agency for visit scheduling, 911 for chest pain, trouble breathing, a fall with injury or sudden confusion, the Aging Commission of the Mid-South at (901) 222-4111 for in-home help, and TN SHIP at 1-877-801-0044 for Medicare coverage questions.
Frequently asked questions
Does Medicare pay for help at home after a hospital stay?
Medicare pays for intermittent skilled home health visits for homebound patients under a doctor's plan, not for hourly non-medical help.
What if observation status ruled out rehab?
Ask the physician whether home health can provide therapy at home, and whether a rehab stay is possible under a Medicare Advantage plan's rules.
Who can help arrange in-home help in Memphis?
The Aging Commission of the Mid-South at (901) 222-4111 screens for TennCare CHOICES and enrolls people in OPTIONS for Community Living.
When should we consider assisted living instead?
When needs arise at unpredictable times, especially at night, or when the hours of help required approach the cost of an ACLF.
