What to settle before discharge day, what to watch in the first 72 hours, and how to pay for the help that comes next.
📞 (443) 402-1039Discharge usually happens faster than families expect, and the hard part starts after everyone goes home.
This checklist covers the four things that actually determine how the first weeks go: what to settle before discharge, the first 72 hours at home, making the home safe, and knowing which warning signs mean call now.
Work through it with whoever is being discharged if they are able to take part. Print it, or ask the discharge planner for a copy. Clinical staff and case managers can find the professional version on our resources for discharge teams.
Every item here is far easier to resolve while you still have the care team in front of you.
Most avoidable readmissions trace back to something in this list.
Do this before the person comes home, with the discharge instructions in hand. A fall in week one undoes everything the hospital stay accomplished.
Chest pain or pressure · sudden trouble breathing · face drooping, arm weakness, or slurred speech · sudden severe headache · unresponsiveness or a seizure · a fall with a head injury, or any fall on a blood thinner · heavy bleeding that will not stop.
When you call, have the medication list and your written log in front of you. It changes the quality of the answer you get.
Families are routinely surprised by this, usually in week two when the home health visits end.
| Skilled home health | Personal care / home care | |
|---|---|---|
| What it is | Short-term clinical care ordered by a doctor: nursing, physical therapy, occupational therapy, speech therapy. | Ongoing hands-on help with daily life: bathing, dressing, toileting, mobility, meals, supervision. |
| How long | Weeks. It ends when the clinical goal is met. | As long as it is needed. |
| Visit length | Typically a short visit, a few times a week. | Shifts — a few hours a day up to 24-hour care. |
| Who pays | Commonly Medicare, when criteria are met, and it is billed by a Medicare-certified home health agency. | Medicaid, long-term care insurance, or private pay. Medicaid options here. |
| The gap | Home health ending does not mean the person no longer needs help. It means the clinical episode is over. The daily help usually still has to come from somewhere. | |
Rising Star is a Maryland licensed Residential Service Agency (RSA), Level 3 — the right-hand column. Our RSA licence covers skilled nursing delivered at home under RN supervision, but we are not a Medicare-certified home health agency and we do not bill Medicare. If a doctor has ordered Medicare home health, that comes from a separate certified agency — and the two commonly run alongside each other.
If the person is on Medicaid or could qualify, this is the first place to look. Community First Choice has no waiting list and covers the personal care most families need. The Community Options Waiver has a registry with a wait that can run for years — which is why being told “there is a waiting list” is not the end of the conversation.
Start at Maryland Access Point: 844-627-5465.
If the person is being discharged from a nursing facility where Medicaid paid for at least 30 days, they may be able to apply for the Community Options Waiver without going through the registry. Ask the facility social worker for a referral to an options counselor before discharge.
If you are the one providing the care, Maryland's self-directed option may allow you to be paid for some of it. Read how that works and what its limits are before you plan around it.
Check the policy for the elimination period — the number of days you must pay out of pocket before benefits start — and whether it requires a licensed agency. Most do.
Hourly, with no eligibility process and no waiting. Many families use private pay to bridge the gap while a Medicaid application is in process.
If the person is a veteran or a surviving spouse, ask the VA about Aid and Attendance and about VA-funded home care programs.
Program rules and financial limits change annually. Verify current figures with Maryland Access Point (844-627-5465) or your local Department of Social Services. This page is general information, not legal or benefits advice.