Leaving the Hospital With Home Health: First 48 Hours

The discharge papers say "home health." Your mom or dad is home, or about to be. Somebody said a nurse would call. Now it's the next morning and the phone hasn't rung.

I'm an occupational therapist, and I've been one of the people who walks into the home after a hospital stay. I've also seen the other side of it: families sitting by the phone, not sure whether to wait or start calling. This guide is for that gap. It covers when the first visit is due, what to get ready, and who to call, in order, if nobody comes.

When the First Visit Is Due

Medicare has a rule for this. It's in the Conditions of Participation that every Medicare-certified home health agency has to meet. The rule says, word for word:

"The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner-ordered start of care date." (42 CFR §484.55(a)(1))

So there are three ways that date can be set:

Within 48 hours of the referral.
Within 48 hours of the patient's return home.
On the start of care date the doctor or allowed practitioner ordered. If the doctor wrote a specific day, the rule allows the visit to be on that day.

That is all the rule says about timing.

The same section says who comes. A registered nurse does the initial assessment visit. When physical therapy or speech therapy is the only service ordered, that therapist may do it instead. For Medicare, an occupational therapist may do it only when OT is ordered along with PT or speech (42 CFR §484.55(a)(1) and (a)(2)).

The first thing I'd ask the hospital before you leave is: which agency was the referral sent to, and did the doctor write a start date?

What Happens at That First Visit

The rule calls the first visit the initial assessment visit. Its purpose, in the rule's words, is "to determine the immediate care and support needs of the patient", and for Medicare patients, to check eligibility for home health, including whether the person is homebound.

There's a second, longer assessment too. The comprehensive assessment must be done "no later than 5 calendar days after the start of care" (42 CFR §484.55(b)(1)). In my experience, many agencies do both at that first visit, so plan for it to take a while. Expect a lot of questions about health history, medicines, the home and how your parent is getting around. Our guide to what to expect at the first home health visit walks through it step by step.

The agency must also give the patient and caregiver written instructions that include the visit schedule, the medication schedule and the name and contact information of the clinical manager (42 CFR §484.60(e)). The rule doesn't say at which visit. Once you have that paper, you know who to call.

The Hospital's Part

Hospitals have their own Medicare rules for discharge planning (42 CFR §482.43). For someone going home with home health, the parts a family should know are short:

The discharge plan must include a list of Medicare home health agencies that are available and serve the area where the patient lives.
The hospital must tell you about your "freedom to choose" and must not limit which qualified agencies you can use.
If the hospital has a financial interest in the agency it refers you to, the discharge plan must say so.
If your parent is in a managed care plan, the hospital must tell you to check with the plan which providers are in its network.
At discharge, the hospital must send the agency the medical information it needs about the patient's illness, treatment and goals (42 CFR §482.43(b)).

One more detail from the same rule: agencies have to ask to be put on a hospital's list. An agency that isn't on the list may still serve your area. If you want to compare agencies yourself, our guide on how to choose a home health agency walks through it.

If the Referral Came From the Doctor's Office

Not every start is a hospital discharge. Sometimes the doctor orders home health after an office visit, and your parent was home the whole time. Then there's no return home to count from. The options left in the rule are within 48 hours of the referral, or on the start date the doctor ordered.

What to Have Ready

None of this is a rule. It's what I've seen make that first visit go smoothly.

The discharge papers, including the medication list from the hospital.
Every medicine in the house, in the bottles. Prescriptions, over-the-counter pills, vitamins, inhalers and creams. The nurse will want to compare them to the list.
Insurance cards: Medicare, any Medicare Advantage or supplement card, and Medicaid if your parent has it.
The doctor's name and phone number, especially the doctor who ordered home health, if it's not their usual doctor.
The agency's name and phone number. Ask the hospital for it before you leave if it isn't on the papers.
A notebook. Write down every call: the date, the time, who you talked to and what they said. If you have to call three places tomorrow, this is the thing that saves you.

If the medicine bottles at home don't match the discharge list, don't guess. Call the doctor's office or the pharmacist and ask.

Who to Call If Nobody Has Called or Come

The order below is my suggestion, not a rule. It goes from the people who can fix it fastest to the people who can look into it after.

1. The agency

Call the number on the discharge papers. Ask if they received the referral, whether they've accepted it, and when the first visit is scheduled. If they say they can't take the case, ask them to tell you today, so you can move on.

In my experience, the most common reason for silence is ordinary: the referral is still sitting in an intake queue, or the agency has no nurse free for your area. Medicare's own booklet notes that your choice of agency "may be limited by agency availability".

2. The hospital discharge planner or case manager

They sent the referral, and in my experience they usually know which agencies are taking new patients in your area. Ask whether the referral went through, and if the first agency can't come, ask them to send it to another one.

3. The doctor who ordered home health

If the first agency has fallen through, the doctor's office can help. Medicare's booklet, on changing agencies, says to contact your doctor "to get a referral to a new agency."

4. 1-800-MEDICARE

1-800-MEDICARE (1-800-633-4227) is Medicare's main help line. Medicare.gov says you can talk with a real person 24 hours a day, 7 days a week, except some federal holidays. TTY users can call 1-877-486-2048. Medicare's booklet says to call if you have questions about your Medicare home health benefits or coverage.

Medicare.gov also says you can call 1-800-MEDICARE to get the contact information for your State Survey Agency, which Medicare's booklet describes as the agency that "inspects and certifies home health agencies for Medicare".

5. The state hotline or State Survey Agency, for complaints

Every patient has a right to be told about the state's toll-free home health hotline, which takes complaints or questions about local agencies (42 CFR §484.50(c)(9)). Medicare's booklet says the agency "should give you this number when you start getting home health services." The agency must also give the administrator's name and phone number for complaints, and the rule says that happens during the initial evaluation visit (42 CFR §484.50(a)(1)). So if nobody has come yet, you probably don't have either number. That's why 1-800-MEDICARE is step 4.

My honest take: if an agency simply turned the referral down, there's nothing to complain about. Get the referral sent somewhere else. The complaint route is for an agency that said it would come and kept not coming.

If your parent has Medicare Advantage

Call the plan early, alongside the agency, using the number on the card. Medicare's booklet says a Medicare Advantage plan "may require that you get home health services from agencies they contract with." Ask the plan whether the agency is in its network and whether anything still needs the plan's approval. Our guide to Medicare Advantage prior authorization for home health explains how plan approval works.

While You Wait

This part is general safety, not medical advice.

If it's an emergency, call 911. Don't wait for the home health nurse.
If something seems wrong but isn't an emergency, call the doctor's office.
Follow the discharge instructions you were given. If something in them isn't clear, call the number on the papers and ask.
Make the path easy. Clear the route between the bed, the bathroom and the kitchen, and keep a light on at night. As an OT, that's the first thing I look at in a home.

If You Want the Agency's Side

This article is for families. If you want to see how the timeline looks from inside an agency, our article on the 48-hour rule goes through the rule in detail, and from referral to first visit walks through every step an agency takes before it can knock on your door.

Frequently Asked Questions

How soon should home health come after the hospital?

Medicare's rule says the first visit, called the initial assessment visit, must happen within 48 hours of the referral, or within 48 hours of the patient's return home, or on the start of care date the doctor or allowed practitioner ordered. Ask the hospital which agency was sent the referral and whether the doctor wrote a start date.

Is the first home health visit the full assessment?

The first visit is the initial assessment, done by a registered nurse, or by a physical or speech therapist when therapy is the only service ordered. The full comprehensive assessment must be finished no later than 5 calendar days after the start of care. In my experience, many agencies do both at that first visit.

Who do I call if home health never shows up?

Start with the agency. If you can't reach it or it can't come, call the hospital discharge planner or case manager, then the doctor who ordered home health. 1-800-MEDICARE can answer questions and give you the contact information for your State Survey Agency. If you have a Medicare Advantage plan, call the plan.

What if the agency the hospital picked can't take us?

You can ask for another one. The hospital must give a list of Medicare agencies that serve your area and tell you that you are free to choose. Medicare's booklet says choices can be limited by which agencies are available, so ask the doctor or discharge planner to send the referral to another agency.

Sources

If the agency can't take you, find another that serves your ZIP

The Medicare-certified home health agencies that serve your ZIP code, from Medicare's Care Compare data, with phone numbers and star ratings.

Find an agency

Leaving the Hospital With Home Health: The First 48 Hours, and Who to Call If Nobody Comes