The first weeks home after a hospital stay: what to expect and what to watch for

Coming home from the hospital feels like the finish line. For many families it’s the start of the hardest part: new medicines, new instructions, a person who is weaker than before, and no nurse down the hall. The first weeks home are when small problems turn into a trip back to the emergency room, and they’re also when good help at home makes the most difference. This note walks through what should happen in those weeks, with Medicare’s rules, and what to watch for.

The short answer

• If the doctor orders home health, a nurse or therapist’s first visit must happen within 48 hours of the referral or of getting home, or on the start date the doctor orders.¹
• A full assessment follows within 5 days, including a review of every medicine the person takes.¹
• The person’s own doctor should see them soon after discharge. Medicare pays doctors for this follow-up, which includes a contact within 2 business days and a visit within 7 or 14 days.²
• Many problems give warning signs first. Knowing them, and who to call, can prevent a trip back to the hospital.

Before you leave the hospital

The hours before discharge are the best time to get answers, because the people who know the most are still in the building. Ask for:

• A written list of every medicine, with what changed: what’s new, what stopped, and what has a new dose
• The discharge summary and any instructions for wounds, diet or activity
• The follow-up appointments, with dates, or who will call to set them
• The home health referral, if the doctor ordered it, and the agency’s name and number
• Equipment the person will need at home, like a walker, a shower chair or oxygen

If the person qualifies for home health, you can ask for a specific agency. Medicare requires hospitals to tell patients they’re free to choose among the agencies available to them.⁴

The first 48 hours

Home health’s first visit must happen within 48 hours of the referral, within 48 hours of the person getting home, or on the start date the doctor orders.¹ At HealthView, intake reaches out the same day the referral comes in, and a nurse visits within 48 hours of the person getting home.

That first visit is about safety: How is the person doing? Do they have their medicines? Can they get to the bathroom safely? Is anything about to go wrong? Within 5 days, the agency completes a full assessment and builds the plan of care with the doctor.¹

The medicines check

A hospital stay often changes a person’s medicines, and the old bottles at home don’t know that.

Home health’s assessment must include a review of all the medicines the person is using, to catch side effects, drug interactions, duplicate medicines, medicines that aren’t working and doses that aren’t being taken.¹ Help the nurse by gathering every bottle in the house in one bag, including vitamins, supplements and anything bought without a prescription, along with the discharge list.

Then make one current list and keep it on the refrigerator. Throw nothing away until the nurse and the doctor agree it’s stopped.

The follow-up visit

The person’s regular doctor should see them soon after they get home. Medicare pays doctors’ offices for transitional care: a call or other contact within 2 business days of discharge, a visit within 7 days for complex cases or 14 days for others, and a review of medicines by the time of that visit.²

In one picture

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Home health

within 48 hoursa nurse visitsWithin 5 daysa full assessment

doctors’ offices

within 2 business days of dischargea call or other contact7 daysfor complex cases14 daysfor others

1. within 48 hoursa nurse visitsHome health
2. within 2 business days of dischargea call or other contactdoctors’ offices
3. Within 5 daysa full assessmentHome health
4. 7 daysfor complex casesdoctors’ offices
5. 14 daysfor othersdoctors’ offices

Sources · law.cornell.edu, hhs.gov

If no one from the doctor’s office has called within two days, call them. Bring the discharge papers and the medicine bag to the visit.

A simple daily check

For the first two weeks, a few minutes each morning catches most changes early. Ask, and write the answers down:

• How did you sleep, and how is your pain?
• Is your breathing the same as yesterday, or harder?
• Are you eating and drinking?
• Did you take every medicine on the list?
• Any trouble with the bathroom, a wound or your balance?

Keep the notes by the medicine list. When the nurse visits, they’ll show what changed and when.

Warning signs to call about

Call the home health agency or the doctor the same day for:

• A fever, chills or a wound that’s red, swollen, draining or more painful
• Shortness of breath that’s new or worse, or swelling in the legs that’s new or worse
• New confusion, unusual sleepiness or a change in behavior
• Not eating or drinking, or vomiting
• A fall, even without an obvious injury
• Not being able to take medicines as prescribed, for any reason

Call 911 for chest pain, severe trouble breathing, signs of a stroke like a drooping face or sudden weakness on one side, or anyone who can’t be woken.

Getting stronger

Many people come home weaker than they went in. Physical and occupational therapists at home help with walking, getting in and out of bed and the shower, and doing everyday tasks safely again. Medicare covers therapy at home when the conditions for home health are met.³

Falls are a real risk in these weeks. Clear walkways, add night lights, keep the walker within reach, and ask the therapist to look at the bathroom. Our note on preventing falls walks through the home room by room.

The family’s part

Families do more than they realize in these weeks: noticing changes, keeping medicines straight, getting the person to appointments, and calling early when something seems off. Ask the home health nurse to teach you what to watch for. You know the person’s normal better than anyone, and “he just doesn’t seem right” is worth a call.

Questions families ask

How soon will the home health nurse come?

The first visit must happen within 48 hours of the referral or of getting home, or on the start date the doctor orders.¹

Does my mom need to see her own doctor if home health is coming?

Yes. The doctor oversees the plan of care, and a follow-up visit within 7 to 14 days is part of a safe return home.²

What should we do with her old medicines?

Gather them all for the nurse’s review, and don’t throw anything away until the nurse and the doctor agree.¹

Can we choose which home health agency comes?

Yes. The hospital must tell you that you’re free to choose among the agencies available to you.⁴

Will Medicare pay for therapy at home?

When the person qualifies for home health, Medicare covers physical, occupational and speech therapy at home.³

Sources

Sources · 4 references

1. 42 CFR 484.55, “Condition of participation: Comprehensive assessment of patients.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
2. Centers for Medicare & Medicaid Services, Medicare Learning Network, “Transitional Care Management Services,” MLN908628, August 2025. hhs.gov (opens in a new tab)
3. Medicare.gov, “Home health services.” Centers for Medicare & Medicaid Services. medicare.gov (opens in a new tab)
4. 42 CFR 482.43, “Condition of participation: Discharge planning.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)