My dad is being discharged and can't go home alone. What are my options?

Make these three calls, in this order

If you are reading this today, start here and read the rest afterwards.

1. The hospital discharge planner or social worker. Ask for them by name at the nurses’ station and ask for a meeting before the discharge date is set, not after.

Ask them:

• What is his discharge destination on the current plan, and why that one?
• Does he qualify for a skilled nursing facility rehabilitation stay? Has he had a qualifying inpatient stay?
• Is he being referred for Medicare home health? If not, why not – is it the homebound test or the skilled-need test that he fails?
• What equipment is being ordered, and who is delivering it before he gets home?
• Can I have the discharge summary and medication list in writing?
• I am telling you he cannot safely be alone. Please record that in the notes.

You are entitled to written notice of discharge and to appeal a Medicare discharge decision. If the plan does not look safe, say so clearly and ask for it in the record.

2. The Area Agency on Aging. In metro Atlanta this is the Atlanta Regional Commission, through its Empowerline service. This is the state’s front door for older adults, and it runs the Aging and Disability Resource Connection.

Ask them:

• What programs might he be eligible for, given his income and his care needs?
• Is there anything available in the short term while a longer application runs?
• Is there a waiting list, and can he be placed on it now?
• What do you need from me to open a file today?

3. A case management agency. This is the agency that would coordinate Elderly and Disabled Waiver Program services if he enrolls.

Ask them:

• Based on what I have described, does the waiver look like a plausible fit?
• What does the assessment involve, and what do you need from his physician?
• What is the realistic sequence and timing from here?
• What happens if he is still in the hospital or in rehabilitation when the assessment is due?

Medicaid pays the case management agency directly. No bill for case management goes to him or to you. You have the right to choose which agency you work with and to change later; see choosing your provider.

The honest part: the waiver will not solve this week

Enrollment in the Elderly and Disabled Waiver Program realistically takes two to six months from first contact to services starting, and there is often a waiting list because the program has a limited number of funded slots.

That is not a reason to delay starting. It is a reason to run two tracks at once: begin the waiver process now, and separately arrange cover for the next few weeks.

What can bridge the gap

Medicare home health. If a doctor orders it, he is homebound, and he has a genuine skilled need – nursing or therapy – a Medicare-certified agency can start visits at home, including a home health aide for personal care alongside the skilled service. It does not require a prior hospital stay. It is reviewed in certification periods and ends when the skilled need ends, which is usually weeks rather than months. Ask the discharge planner to set this up before he leaves.

A skilled nursing facility rehabilitation stay. After a qualifying inpatient hospital stay, Medicare can cover a limited period in a skilled nursing facility for rehabilitation, with cost sharing after the first stretch of days. It is not long-term care, but it buys real time and often improves his function before he goes home.

Inpatient rehabilitation. For some conditions, a more intensive rehabilitation setting is appropriate. The discharge planner will know whether he meets the criteria.

Privately paid home care. Bought by the hour from a home care agency, with no eligibility test and no waiting list, but paid from his or the family’s own funds. Many families use this for the first weeks and step it down as other cover arrives. It is a legitimate stopgap and worth pricing before you need it.

Family cover. Shifts, a rota, someone moving in for a while. Do not plan this on optimism. Write out the actual week, hour by hour, including nights, and see whether it holds for six weeks rather than six days. If a relative is going to move in permanently, read getting paid as a family caregiver, because a co-resident relative may later be relevant to Structured Family Caregiving once he is enrolled.

Other local supports. The Area Agency on Aging can point you to meal programs, transportation and volunteer services that are not part of the waiver. These do not replace hands-on care, but they take load off the week.

What to have ready before any of these calls

• His Medicare and Medicaid numbers
• The discharge summary and current medication list
• His diagnoses and the name and phone of his regular physician
• Any power of attorney, healthcare directive or guardianship paperwork
• A plain written list of what he cannot do alone: stairs, bathing, transfers, toileting at night, cooking, managing pills
• A rough picture of income and assets, which the financial side will need

Having these in one folder is worth an hour and saves several days.

What happens next on the waiver track

Once the process starts, the sequence is an assessment of level of care using the DON-R alongside a medical form called the DMA-6, then approval of a plan of care – which under General Services §602.11 can be attested either by his own physician or by the case management agency’s medical director – then the financial review, then a slot, then providers being arranged and services starting.

The timeline page sets out what happens in each stage, and do I qualify covers the two tests.

Nothing here is a determination of eligibility, and no page can promise a place or a date.