Hospital discharges often happen faster than families expect. The doctor says “looks good, you can go home tomorrow,” and suddenly there’s a 24-hour window to figure out who’s going to help your loved one bathe, dress, get to follow-up appointments, manage medications, and stay safe during recovery. This guide is what we wish every Philadelphia family knew before the discharge papers come.
If you’re reading this with a discharge already scheduled — or your loved one is already home and you’re realizing how much help they need — start with the urgent step list below. If you have more time to plan, the full guide walks through what to expect over the first 24 hours, the first two weeks, and the most common mistakes families make.
Call 215-730-1020. We can have a caregiver in your loved one’s home within 24 to 48 hours of the free assessment for private pay families — and we can start short-term private pay even if you’re applying for the CHC Medicaid Waiver in parallel.
Why Post-Hospital Care Matters More Than People Realize
Hospital discharge is one of the riskiest moments in a senior’s medical care. Studies consistently show that roughly 1 in 5 older adults discharged from the hospital is readmitted within 30 days — often for entirely preventable reasons: a fall, a medication error, an infection caught too late, an unfilled prescription, dehydration, or a missed follow-up appointment.
The first two weeks after discharge are when most of these readmissions happen. Your loved one is weaker than usual. They may be on new medications they aren’t used to. They might be confused from anesthesia or pain medication. The home they’ve lived in for years can suddenly contain hazards they didn’t notice before — a loose rug, a low toilet, a tub that’s now hard to get out of.
None of this is dramatic. It’s just the reality of recovery. The families who navigate it well are usually the ones who set up support quickly and don’t try to muscle through alone.
The First 24 to 48 Hours After Discharge
If your loved one is being discharged in the next day or two, here’s the order to do things in. Don’t try to do it all at once — work the list.
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1
Read the discharge paperwork carefully — twice
Discharge instructions usually include new medications, what to watch for, when to call the doctor, and follow-up appointment timelines. Read it slowly. If anything is unclear, call the discharging doctor’s office before you leave the hospital. Don’t assume “I’ll figure it out at home” — figure it out now.
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2
Pick up prescriptions same day
The single most common reason for readmission is missed or delayed medications. If new prescriptions are part of the discharge plan, get them filled before your loved one gets home. If your loved one is being discharged at 4 PM on a Sunday, plan for which pharmacy is open. CVS and Walgreens locations across Philadelphia have 24-hour or extended-hour pharmacies — confirm which one closest to your loved one’s home is open when you’ll need it.
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3
Set up the home for safe recovery
Walk through your loved one’s home with fresh eyes. Remove throw rugs (the most common fall hazard for older adults). Clear paths to the bathroom and kitchen. Make sure there’s a phone within reach of the bed. Move frequently used items to easy-to-reach shelves. If they’ve been prescribed a walker or cane, set it where they’ll need it — by the bed, by the bathroom, by the door.
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4
Confirm follow-up appointments
Most discharge plans include at least one follow-up appointment within 7 to 14 days. Make sure it’s on the calendar. Arrange transportation in advance — recovery isn’t the time to figure out who’s driving on the morning of the appointment.
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5
Arrange for someone to be present the first 72 hours
This is the part families most often underestimate. Even if your loved one “seems fine” at discharge, the first three days at home are when most things go wrong. Someone — a family member, a friend, or a paid caregiver — should be at the home, not just checking in by phone. If family can cover the first day or two, plan for paid help to bridge the gap before everyone goes back to work.
The First Two Weeks at Home
Recovery is rarely a straight line. Your loved one will probably have a good day, then a setback, then another good day. That’s normal — and it’s why the first two weeks call for more support than families typically expect.
Things to watch for during this period:
- Increasing pain or swelling at a surgical site or injury
- Fever above 100.4°F, which can signal infection
- Confusion that’s new or worsening — sometimes a sign of medication interaction or dehydration
- Falls or near-falls — even a “soft fall” with no injury is worth reporting to the doctor
- Loss of appetite or weight — common after hospitalization, but can spiral quickly if it persists
- Difficulty managing medications — wrong dose, missed dose, doubled dose
- Withdrawal or depression — recovery is mentally hard; the family caregiver should know to watch for it
If any of these show up, call the discharging doctor’s office before deciding what to do. Many “should we go to the ER?” moments can be handled with a phone call to the practice’s nurse line.
How Home Care Helps During Recovery
Post-hospital home care isn’t medical care — it’s the daily-life support that keeps your loved one safe and recovering well so the medical care can do its job. A typical post-discharge home care arrangement covers:
- Personal care — bathing, dressing, mobility help. Critical when balance or strength isn’t fully back.
- Medication reminders — gentle, consistent prompting to take the right meds at the right time. (Caregivers don’t administer; they remind.)
- Meal preparation — nutritious meals matched to dietary restrictions from the discharge plan.
- Light housekeeping — laundry, kitchen cleanup, keeping the recovery space clean and clutter-free.
- Transportation — to follow-up appointments, the pharmacy, the lab for blood work.
- Safety monitoring — watching for the warning signs above and reporting back to family.
- Coordination with home health — if your loved one has a home health nurse or physical therapist coming, we work around their schedule and complement their visits.
- Companionship — recovery is lonely, especially for seniors who live alone. Having someone in the home helps.
Common Discharge Mistakes Families Make
We see the same mistakes over and over. Here are the ones worth knowing about in advance.
RealityOlder adults often underestimate what they need — partly out of pride, partly because they don’t want to be a burden, partly because they don’t know what’s about to be hard. Discharge from the hospital is not the moment to take “I’m fine” at face value. Plan for help. If three days in she truly doesn’t need it, you can scale back.
RealityFamily is wonderful. Family is also working full-time jobs, raising kids, and living miles away. Most family caregivers can sustain intense help for about a week before exhaustion sets in. Plan for paid backup from day one — even just a few hours a day — so the family doesn’t burn out by week two.
RealityA daily check-in is great but not enough. Falls happen at 2 AM. Medication confusion happens at lunchtime. The bathroom is hard at every hour. The first week home, your loved one needs presence, not check-ins.
RealityTwo weeks of help during recovery often prevents a setback that would extend recovery to two months — or worse, send your loved one back to the hospital. The cost of a few weeks of part-time care is far less than the cost of a single readmission, in dollars and in stress.
RealityMedicare covers home health — short-term skilled nursing, physical therapy, occupational therapy — for a limited number of days following a hospital stay. It does not cover ongoing non-medical home care (bathing, dressing, meals, supervision). Most families pay for post-hospital home care privately, use long-term care insurance, or apply for Pennsylvania’s CHC Medicaid Waiver. See our cost guide for details.
Coming Home From a Philadelphia-Area Hospital
We work with families being discharged from every major hospital in the Philadelphia region. Each hospital’s discharge planning team is a little different, but the core process is the same: a case manager or social worker helps coordinate next steps, sometimes including referrals to home care.
Hospitals where we frequently support post-discharge clients include:
- Penn Medicine — Hospital of the University of Pennsylvania (HUP), Penn Presbyterian Medical Center, Pennsylvania Hospital
- Jefferson Health — Thomas Jefferson University Hospital, Jefferson Methodist Hospital, Jefferson Frankford Hospital
- Temple Health — Temple University Hospital, Jeanes Hospital
- Mercy Catholic Medical Center — Darby and Philadelphia campuses
- Crozer Health — Crozer-Chester Medical Center, Taylor Hospital, Springfield Hospital
- Lankenau Medical Center — Wynnewood
- Bryn Mawr Hospital — Bryn Mawr
- Riddle Hospital — Media
If your loved one is at any of these hospitals, ask the discharge planner about home care options early — ideally a day or two before the planned discharge, not the morning of. The case manager can give you referrals; you can also call us directly to set up an assessment.
How to Set Up Post-Hospital Care Quickly
The realistic timeline for setting up home care after a hospital discharge depends on how it’s being paid for:
Private Pay
Care can typically begin within 24 to 48 hours of your initial call. We can come to the home for the assessment, build a care plan around the discharge instructions, match a caregiver, and start. This is the fastest path and the right fit for the immediate post-discharge period — even if you plan to apply for CHC Medicaid Waiver later.
CHC Medicaid Waiver
The CHC application takes 30 to 45 days, so it can’t be the answer to “I need help tomorrow.” But it can be the answer to “I need help for the next year” — many families bridge the first month with private pay and transition to CHC coverage once approved. See our CHC guide for the full eligibility rules and application process.
Long-Term Care Insurance
If your loved one has an LTC policy, pull it out of the file. Most policies cover post-hospital home care, but check the elimination period (the waiting period before benefits start) — for some policies it’s a few days, for others it’s 90 days. We work with most major LTC carriers and can help you understand what’s covered.
Veterans Aid & Attendance
If your loved one is a wartime veteran or surviving spouse, the VA Aid & Attendance benefit can provide significant monthly support toward home care. The application takes time, but for veteran families this benefit is often life-changing.
See our cost guide for what affects pricing, our care setup process page for what happens at each step, and the 7 questions to ask any agency before you sign.
Frequently Asked Questions
Will Medicare pay for home care after a hospital stay?
Medicare covers home health — short-term skilled nursing, physical therapy, and occupational therapy — for a limited number of days following a qualifying hospital stay, typically prescribed by the discharging doctor. Medicare does not cover ongoing non-medical home care like bathing, dressing, meals, or supervision. For that kind of care, families pay privately, use long-term care insurance, qualify for Pennsylvania’s CHC Medicaid Waiver, or use VA benefits.
How quickly can post-hospital care start?
For private pay families, care can usually start within 24 to 48 hours of your call. We come to the home for the free assessment, build a care plan around the discharge instructions, match a caregiver familiar with post-hospital recovery, and begin. If your loved one is being discharged today or tomorrow, call us right away — we’ll work the timeline backward from when you need us.
What if my loved one is being discharged tonight or tomorrow?
Call us immediately at 215-730-1020. We’ve set up post-discharge care on day-of timelines before. The earlier in the day you call, the more options we have. If we can’t get a caregiver to the home in time, we’ll tell you honestly and help you think through other options for the first 24 hours (family coverage, hiring a private caregiver short-term, etc.).
What if my loved one refuses help?
This is common. Strategies that often work: introduce the caregiver as “help around the house” rather than “someone to take care of you.” Start with companion care first (less invasive than personal care). Have the caregiver visit while a family member is also there for the first session, so it doesn’t feel like strangers. If your loved one has dementia, the conversation is different — talk to your care coordinator for specific approaches. Refusal often softens within the first week.
Can the home care agency coordinate with home health?
Yes — and we frequently do. Home health (Medicare-covered skilled nursing, PT, OT) and home care (non-medical daily support) are complementary, not duplicates. We schedule around home health visits, share observations with the home health team when relevant, and pick up the daily-life support that home health doesn’t cover.
What if my loved one is on the CHC Medicaid Waiver?
If they’re already approved and have authorized hours, we can begin care under the waiver as soon as your MCO clears us. If they’re not yet on the waiver but you want to apply, we can start short-term private pay to bridge the application period (30 to 45 days) and transition to waiver coverage once approved. See our CHC guide for the full process.
How many hours of post-hospital care does my loved one need?
It depends on the recovery, but a common starting point for the first two weeks is 4 to 6 hours per day, 5 to 7 days a week — enough to cover bathing, meals, medication reminders, light housekeeping, and supervision. Many families taper down after the first two to three weeks as recovery progresses. Some scale up if recovery is slower than expected. The schedule should serve the recovery, not the other way around.
What’s the difference between home care and home health care?
Home health is medical: skilled nursing, physical therapy, occupational therapy, wound care. It’s typically prescribed by a doctor, covered by Medicare for a limited period, and delivered by licensed clinical professionals. Home care, like what we provide, is non-medical: help with daily activities, companionship, meals, transportation, and household tasks. They’re often used together — home health for the medical recovery, home care for everything else.