The First Week After an Upstate Hospital Discharge

Before discharge: three questions

Ask the hospital case manager, in writing, whether your parent was admitted as an inpatient or kept under observation. Medicare pays for skilled nursing rehab only after three inpatient days, and observation days do not count. Ask what level of care the team recommends next, and ask for the list of facilities or agencies that can accept your parent now. You have the right to choose from that list.

DPH's roster lists 11 general acute-care hospital campuses in our four counties. These are the ones families most often deal with:

Inpatient rehabilitation hospitals, such as Encompass Health's in Greenville and AnMed's in Anderson, are a separate, more intensive option for patients who can handle about three hours of therapy a day.

Day 1: the trip home or to rehab

If your parent is going to a nursing home for rehab, bring the discharge summary, medication list and insurance cards, and ask when the first therapy evaluation will happen. Our nursing home pages show each home's CMS ratings, latest inspection and staffing next to the four-county median, which helps when the hospital's list is long.

If your parent is going home, fill new prescriptions before leaving the hospital. Pharmacies close; pain does not. Make sure someone stays the first night.

Days 2 and 3: home health starts

If a doctor ordered home health, the agency should call within a day or two to schedule the first nursing visit. Ask how often the nurse and therapists will come and who to call after hours. Medicare pays for these visits for a homebound patient; it does not pay for an aide to stay for hours at a time.

If your parent needs more daily help than home health provides, a DPH-licensed in-home care provider can often start within days. Our in-home care roster lists every licensed provider in the four counties, searchable by city.

Days 4 to 7: watch for warning signs

Watch for new confusion, fever, shortness of breath, swelling, a wound that looks worse, or pain that is not controlled. Call the doctor's office or home health nurse rather than waiting. Make sure the follow-up appointment with the primary care doctor happens within a week or two; many readmissions follow a missed follow-up.

Remove trip hazards on the path from bed to bathroom, add a night light, and put a phone or alert device within reach. A first fall after a hospital stay is common and often preventable.

Keep a one-page record

Families who keep a single page with the discharge date, diagnoses, every medication with its dose and time, the home health agency's phone number, the follow-up appointment and the names of the doctors involved handle the first week far better than those who rely on a folder of discharge papers. Tape it inside a kitchen cabinet. Give a copy to anyone who stays with your parent.

Use the same page to note anything that changes: a new symptom, a fall, a call from the doctor. If your parent ends up back in the emergency room at Greenville Memorial, St. Francis or AnMed, that page answers the first ten questions the staff will ask.

If home will not work

If it becomes clear during that week that your parent cannot manage at home, a South Carolina CRCF may be the next step, provided their needs fall within Regulation 60-84's limits. A CRCF cannot admit someone who needs daily skilled monitoring, IV medications, staff-given sliding-scale insulin or treatment for stage 2 to 4 pressure ulcers, but it can bring in short-term nursing for up to 14 consecutive days while a resident recovers.

The CRCF will need a physical examination from within the previous 30 days; the hospital discharge exam often qualifies. The Area Agency on Aging (Appalachian COG at 864-242-9733, Upper Savannah COG for Laurens County) can help sort out options and programs.