Home Care After a Hospital Stay in Pittsburgh: A Discharge Checklist

Why the first weeks at home matter

Readmissions are common. Federal data from AHRQ show that in 2016, Medicare patients had 17.1 readmissions within 30 days for every 100 hospital stays, almost twice the rate of privately insured patients.^[1] In Pennsylvania, people living with dementia had a 22.0% readmission rate.^[4]

Falls are a major risk too. The CDC reports that about 14 million older adults, 1 in 4, report falling each year.^[3] Weakness, new medications, and an unfamiliar routine after a hospital stay all add to that risk.

Hospital discharge checklist

Before you leave the hospital

• Get the written discharge summary and a complete, updated medication list. Ask which old medications to stop.
• Confirm follow-up appointments with dates, and who is driving.
• Ask whether a doctor has ordered home health (nursing or therapy) and which agency will call you.
• Ask for warning signs that mean "call the doctor" versus "go to the ER."
• Order any equipment, such as a walker, shower chair, or raised toilet seat, before you get home.

The first 72 hours at home

• Fill new prescriptions the same day and set up a pill organizer or reminder schedule.
• Clear walkways, add night lights, and move daily items to waist height.
• Plan simple, nutritious meals and keep fluids within reach.
• Arrange for someone to be present for the first showers and the first nights.

The first 30 days

• Keep every follow-up appointment and bring the medication list.
• Watch for changes in confusion, appetite, breathing, swelling, or pain, and write them down.
• Decide how many hours of help are realistic for the family, and fill the gaps early.

Home health vs. home care: what Medicare covers

These terms sound alike but are different services.

• Home health is skilled care (nursing, physical or occupational therapy) ordered by a doctor. Medicare covers it if you are homebound and need part-time or intermittent skilled care.^[2]
• Home care (non-medical) is help with daily living: bathing, dressing, meals, mobility, reminders, and companionship. Medicare does not cover 24-hour care at home, homemaker services, or custodial personal care when that is the only care you need.^[2]

Most families use both. The home health nurse visits a few times a week, and a home care aide fills the hours in between. Veterans may also qualify for the VA's Homemaker and Home Health Aide program.^[5]

How Trinity Home Care helps after a hospital stay

Our post-hospital recovery support covers the non-medical side of coming home: a steady hand for transfers and showers, medication reminders, meals, rides to follow-up visits, and a caregiver who notices when something changes. We can start with longer shifts in the first week and taper down as strength returns.

Call 412-345-3721 before discharge day if you can. It gives us time to plan the first shift around the trip home.