Going Home After a Hospital or Skilled Nursing Facility Stay
Planning for both scheduled and unanticipated emergency hospitalizations will help ensure your safe return home.
PDF in English | PDF in Spanish
Go home strong by following the A–M–P guidelines.
- Advocate for a safe discharge plan
- Maximize insurance and benefit program coverage
- Prepare for changing care needs
A – Advocate for a Safe Discharge Plan
A safe hospital discharge plan is key to remaining in your home. Talk about your post-hospital needs early in your hospital stay. Your written discharge plan should include information about post-hospital treatment needs, where to receive necessary care after discharge, medication and equipment needs, resources for managing your illness, and care costs.
Ask hospital staff to help put post-hospital services in place. Speak up if you are worried that you are not ready to return home. You may also ask for a patient advocate.
New Hampshire has a Patient’s Bill of Rights and a law that allows you to name a trusted person as your designated caregiver. That person may receive information about your post-hospital care needs.
- Patient’s Bill of Rights: Patient’s Bill of Rights
- Caregiver Advise, Record, and Enable Act: RSA 151:43
Federal law requires hospitals to provide discharge planning that reflects the patient’s goals and recognizes the patient’s right to identify a caregiver: 42 CFR 482.43. Federal law also requires prompt resolution of patient grievances: 42 CFR 482.13.
Medicare beneficiaries have additional rights. Within two days of hospitalization, you must receive notice of certain rights, including the right to an expedited review. This notice, called the Important Message from Medicare (IM), provides information about reporting quality-of-care concerns and appealing a hospital discharge.
Hospital quality and discharge issues are handled by a Medicare Quality Improvement Organization (QIO). Acentra Health is the QIO in New Hampshire and provides help at 1-888-319-8452 and through its New Hampshire resource page.
- For more information, speak with your health care provider before hospitalization, request the Medicare & You handbook, or call 1-800-MEDICARE.
- Online resources:
- Discharge planning: caregiver.org/resource/hospital-discharge-planning-guide-families-and-caregivers/ and medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf
- Hospital discharge appeals for Medicare beneficiaries: Acentra Health New Hampshire, Medicare hospital fast appeals, and Center for Medicare Advocacy discharge-planning information
M – Maximize Rehabilitation with Medicare Skilled Nursing Facility Benefits
After hospitalization, you may need skilled care to regain strength. This care may include nursing services or occupational, physical, or speech therapy.
The information in this section applies to most Medicare beneficiaries. Certain requirements may differ if you have a Medicare Advantage plan rather than original Medicare. Review your coverage and contact your Medicare Advantage plan for details.
Medicare may cover skilled care in a skilled nursing facility (SNF) when certain conditions are met:
- You were admitted to a hospital as an inpatient for at least three consecutive days, not including the day of discharge. Time spent receiving emergency-room care or under observation status does not count toward the inpatient requirement.
- You require skilled nursing care seven days per week or skilled therapy five days per week.
- You enter a Medicare-certified SNF within 30 days of leaving the hospital.
Confirm Hospital Inpatient Status
To preserve your right to Medicare SNF benefits, determine whether the hospital has admitted you as an inpatient. The hospital must provide notice if you have not been admitted as an inpatient but have received observation services for more than 24 hours. This notice is called the Medicare Outpatient Observation Notice (MOON).
The source states that the MOON notice is not appealable and links to CMS information about the MOON notice.
A January 2022 court ruling determined that people with original Medicare whose hospital status changed from inpatient to observation may have the right to appeal the observation-status designation. Other Medicare beneficiaries may not have the same appeal right but should still advocate for inpatient status when inpatient-level care is medically necessary.
Appeal a SNF Notice of Non-Coverage
Medicare may pay for up to 100 days of SNF care while skilled services remain necessary. Skilled care should continue when those services are necessary to perform a safe and effective maintenance program.
If a SNF believes Medicare will no longer cover skilled services, it must issue a Notice of Medicare Non-Coverage. The notice explains how to appeal the decision through the QIO. If you believe your SNF benefits should continue, follow the directions in the notice and file an appeal.
- Online resources:
- Outpatient and observation status: Center for Medicare Advocacy
- Appealing a Medicare denial of SNF care: Skilled nursing facility services
- Standard for terminating Medicare SNF benefits: CMS information about the Jimmo settlement
- Appealing termination of Medicare SNF benefits: Medicare fast appeals from non-hospital settings
P – Prepare for Changing Needs
Before returning home, consider your care needs. Will you need home care or outpatient services? Does your home need modifications?
Medicare Home Care Benefits
Under original Medicare, you may qualify for skilled care in your home or as an outpatient. Part-time services may be available in your home if you are homebound and require medically necessary skilled nursing or physical, speech, or occupational therapy.
A doctor must certify that you need home health services. Medicare may also provide medical equipment, such as a wheelchair or walker, to help you remain safe at home. Medicare coverage should not be denied solely because your condition is chronic or stable.
If you have a Medicare Advantage plan, it must provide at least the same level of coverage as original Medicare. Contact your plan for specific details. You may need prior authorization or a referral for home health services, and you may need to use a participating home health agency.
- For more information, request the Medicare & You handbook or call 1-800-MEDICARE.
- Online resources:
- Original Medicare: Medicare and Home Health Care and Center for Medicare Advocacy home-health information
- Medicare Advantage: Medicare Advantage and home health
If your Medicare home-care benefits are being terminated, you should receive a notice explaining your right to an expedited appeal through the QIO. See Medicare’s information about fast appeals from non-hospital settings.
Medicaid Home Care Benefits
If you are medically and financially eligible, Medicaid may provide services in your home. More than one Medicaid program offers home care.
Choices for Independence (CFI) serves people age 18 and older who need help at home. Services may include personal care, household assistance, transportation, delivered meals, adult day services, case management, medical equipment, home modifications, and respite care.
If you apply and are denied, call 603 Legal Aid at 1-800-639-5290.
- For more information, call DHHS at 1-844-275-3447 or ServiceLink at 1-866-634-9412.
- Online resource: Choices for Independence booklet
Veterans Benefits
If you are enrolled in VA health care and have certain medical needs, you may qualify for home-care benefits. Wartime veterans with home-care needs—and, in some cases, their spouses—may qualify for a VA pension known as Aid and Attendance.
If you have a service-connected disability rating of 70% or higher, you and your family caregivers may qualify for other benefits that support remaining at home.
- For more information, call VA Caregiver Support at 855-260-3274 or New Hampshire Veterans Services at 1-800-622-9230.
- Online resources: New Hampshire Veterans Services and VA home- and community-based services
Private Care
Sometimes paying a private agency for services makes sense. Ask whether the agency is licensed, bonded, and insured. Ask about minimum scheduling requirements and whether the agency has enough staff to meet your needs.
Fair Housing Rights
If you rent your home or live in an assisted-living or nursing facility, fair housing laws protect you against discrimination. These laws may also help if you have a disability and need special arrangements or home modifications.
You cannot be treated differently in housing because of race, color, national origin, disability, sex, religion, familial status, age, marital status, sexual orientation, or gender identity.
- For more information, call the Fair Housing Hotline at 1-800-921-1115.
- Online resource: Fair Housing New Hampshire
The substance and findings of this work are dedicated to the public. The author and publisher are solely responsible for the accuracy of the statements and interpretations contained in this publication. These interpretations do not necessarily reflect the views of the federal government.
- NHLA Fair Housing: 1-800-921-1115
- 603 Legal Aid: 603-224-3333 or 800-639-5290
- NHLA Justice in Aging Project: 1-800-353-9944
- Apply online: 603 Legal Aid