The First Week After a Tulsa Hospital Discharge: A Day-by-Day Plan

Before discharge: three questions in writing

Tulsa's large hospitals, Saint Francis, Hillcrest, Ascension St. John and OSU Medical Center among them, discharge quickly, and the case manager's list of options can arrive the same day the doctor says your parent is ready. Ask three things and write the answers down. Was my parent formally admitted as an inpatient, and on what date? What level of care does the team recommend next: home with home health, a skilled nursing facility, or inpatient rehabilitation? Which facilities or agencies have already accepted the referral?

The first question matters because Medicare Part A covers skilled nursing facility care only after a qualifying inpatient stay of at least three days, and observation days do not count. If the answer is observation, ask whether that can be reviewed.

Choosing the rehab home

You have the right to choose among facilities that accept the patient. The temptation is to pick the closest one. Instead, take ten minutes with CMS's data, which our nursing home pages reproduce: look at the health inspection rating, registered nurse hours per resident day and staff turnover, and compare each with the Tulsa-area median. Then call and ask how many therapy sessions a typical rehab patient receives each day and whether therapists work weekends.

The table shows, for each Tulsa County hospital with an emergency department, how many certified nursing homes lie within five miles in a straight line and which is closest.

Days one to three: settle the plan of care

The nursing home will complete an admission assessment and build a care plan. Ask to attend the first care-plan meeting, by phone if necessary. Bring a list of medications from the hospital discharge summary and check it against the home's list; medication changes at transitions are one of the most common sources of error. Ask who the attending physician or nurse practitioner will be and how often they visit.

Visit at different times. A morning visit shows therapy; an evening visit shows staffing.

Days four to seven: plan the exit

Medicare covers the first 20 days of a qualifying skilled stay in full and charges a daily coinsurance after that, and coverage stops when skilled care is no longer needed, which can happen well before day 100. Use the first week to decide where your parent will go next. If home is the goal, ask the therapist what equipment and help will be needed and line up home health and private help. If home is not realistic, start touring assisted living centers now, and check whether any accept ADvantage if that will be needed.

If the nursing home issues a notice that Medicare coverage is ending and you disagree, the notice explains how to request a fast appeal through the Medicare quality improvement organization.

If your parent is going home instead

When the team recommends home with home health, Medicare can cover intermittent nursing and therapy visits for a homebound patient under a doctor's plan, but not hourly help. Ask the case manager which home health agencies have accepted the referral and when the first visit will happen; the first 48 hours at home are when falls and medication mix-ups are most likely. Arrange private help or family coverage for those first nights, fill prescriptions before you leave the hospital, and check that the bathroom is safe. If the person lives alone and the plan depends on everyone doing everything right, it may be worth a short respite stay in assisted living while home health gets started.

Keep a discharge folder

Put the discharge summary, the medication list, the follow-up appointments, the names of the case manager and the attending physician, and copies of any Medicare notices in one folder. Every provider in the next month will ask for something in it, and the person holding the folder is the person who keeps the plan on track.

If the stay becomes long-term

Some patients cannot go home. If your parent will stay as a long-term resident, confirm that the home participates in SoonerCare if that will be needed; a few Tulsa homes are certified for Medicare only. The Medicare Assistance Program (1-800-763-2828) can help with Medicare questions, and the long-term care ombudsman (1-800-211-2116) can help with disputes.