Your Parent Is Coming Home From the Hospital: A New York Guide to Care After Discharge

A hospital may say your parent is ready to go home. Your family may still be wondering: Who will help them get out of bed tomorrow morning? How will they reach the bathroom safely? When will physical therapy begin? What happens if they are frightened to be alone?

A good discharge plan answers those questions before the patient leaves. It may involve medical treatment, rehabilitation, help with daily activities, emotional support, and a longer-term care plan. These needs do not all fall under the same insurance benefit.

For New Yorkers with Medicaid who urgently need help bathing, dressing, using the bathroom, or managing other daily activities, one step is especially important: ask Medicaid about an Immediate Need assessment for personal care services or CDPAP. A Medicare home health referral may address skilled medical or therapy needs, but it generally will not provide ongoing personal care when that is the only help needed.

Before discharge, describe what life at home will actually look like

Tell the hospital discharge planner, social worker, nurse, and treating clinician what your parent can and cannot do safely. Be specific:

Can they get out of bed, stand, walk, and use the bathroom without assistance?

Can they bathe, dress, prepare food, and eat?

Do they need help during the night?

Are they confused, unsteady, or at risk of falling?

Do they need wound care, injections, medication management, or other skilled treatment?

Is someone truly available to help at home? For which hours?

Are they anxious, depressed, frightened, or overwhelmed?

Ask the team to document the patient’s needs, explain the proposed discharge destination, and identify who is responsible for each part of the plan. “Family will help” is not a workable arrangement unless a family member is available and able to provide the necessary help.

If you believe the person cannot safely manage at home under the proposed plan, raise the concern with the discharge team before they leave. Ask what services can start immediately, what remains pending, and how the gap will be addressed.

Understand the different kinds of care

Need after discharge Possible service Where to start

Wound care, certain nursing needs, or qualifying therapy at home Skilled home health services Hospital discharge team and treating clinician Help bathing, dressing, toileting, or with other daily activities Medicaid personal care services Medicaid plan or local Medicaid office Daily help from a caregiver the eligible person chooses and directs Medicaid CDPAP Medicaid plan or local Medicaid office; PPL handles CDPAP fiscal intermediary functions Rehabilitation when the person can attend appointments Outpatient physical, occupational, or speech therapy Treating clinician and therapy provider Short-term, intensive skilled care after a hospital stay Skilled nursing facility or other appropriate rehabilitation setting Hospital discharge team and health plan Counseling or treatment for depression, anxiety, or other mental health needs Outpatient mental health services or other appropriate care Primary care clinician, discharge team, or health plan

A patient may need several of these at once. The goal is to arrange them together, with no assumption that one referral covers every need.

Short-term skilled care: what Medicare may cover

After an illness, injury, or surgery, an eligible patient may receive Medicare-covered home health services. Depending on their circumstances, these can include part-time or intermittent skilled nursing, physical therapy, occupational therapy, speech-language pathology, and medical social services. Medicare may also cover part-time or intermittent home health aide care when the person is receiving qualifying skilled care at the same time. The home health benefit has specific requirements, including a need for qualifying skilled services and being homebound.

For example, someone returning home after surgery might need a nurse to check a wound and a physical therapist to work on walking. Ask the discharge planner whether a home health agency has accepted the referral and when its first visit is expected. A referral that has merely been sent does not tell you when care will begin.

Medicare does not cover 24-hour care at home or personal care that helps with daily living when personal care is the only service needed. Its home health aide benefit is limited and should not be treated as a plan for ongoing daily or overnight assistance.

Some patients need skilled nursing facility care or inpatient rehabilitation before they can safely return home. These settings have their own medical and coverage requirements. Ask the discharge team to explain why the proposed setting fits the patient’s needs and what the patient’s plan will cover. Medicare’s skilled nursing facility benefit is limited; it is not an unlimited benefit for long-term custodial care.

Physical therapy: rebuilding movement and confidence

Physical therapy can be an important part of recovery. A therapist may help a patient regain strength, improve balance, practice walking, use a cane or walker safely, and reduce the risk of falls.

Where should therapy happen? That depends on the person’s condition and ability to leave home. Qualifying patients may receive physical therapy through Medicare home health services. An eligible patient who can attend appointments may receive medically necessary outpatient physical therapy under Medicare Part B. Some patients need a more intensive rehabilitation setting.

Before discharge, ask:

1. Has therapy been recommended, and for what specific goal?

2. Will it take place at home, in a clinic, or in a rehabilitation facility?

3. Which provider has accepted the referral?

4. When is the first visit or appointment?

5. Does the patient need assistance or transportation to attend?

A physical therapist may visit only at scheduled times. Therapy does not replace a caregiver who is needed to help the person move safely, dress, or use the bathroom throughout the day.

Occupational therapy, speech therapy, and everyday skills

Occupational therapy addresses the activities that make daily life possible. A therapist may work with a patient on dressing, bathing, using the bathroom, or moving around the home. They may also recommend equipment or changes to make those tasks safer.

Speech-language therapy may be appropriate after a stroke or another condition affecting communication or swallowing. Ask the treating team whether either service is needed and how it will be arranged. Qualifying Medicare home health services can include occupational and speech-language therapy.

Even as someone improves with therapy, they may need hands-on personal care between visits. Make both plans at the same time.

Emotional support is part of recovery

Going home can bring relief and fear together. A patient may be worried about falling, frustrated by a loss of independence, lonely, or anxious about a new diagnosis. A family caregiver may also be exhausted before home care has even begun.

Ask the patient how they feel about returning home. Tell their clinician about persistent sadness, anxiety, confusion, major changes in sleep or behavior, or difficulty coping. Ask whether they would benefit from a medical social worker, counselor, therapist, or other mental health professional.

Medical social services can be part of qualifying Medicare home health care. Medicare also covers eligible outpatient mental health services, including care for depression and anxiety. The appropriate provider, coverage, and costs depend on the patient’s circumstances and insurance.

Family and friends can help by checking in, providing companionship, helping organize appointments, and listening to what the patient finds difficult. They should also be honest about what they can sustain. If a relative cannot provide daily or overnight care, tell the discharge team and the Medicaid assessor.

Medicaid personal care: help with daily activities

New York Medicaid personal care services may help an eligible person who needs assistance with daily activities. Agency-provided personal care is arranged through an authorized care plan; a home care agency employs and schedules the aides. The person must meet applicable eligibility and assessment requirements, and Medicaid or the responsible plan determines the services authorized.

Do not assume that a hospital discharge automatically starts personal care. Ask who will request the assessment, who will authorize services, and how the patient’s needs will be met while the request is pending.

CDPAP: choosing and directing a caregiver

The Consumer Directed Personal Assistance Program (CDPAP) is a New York Medicaid option that allows an eligible person to choose and direct their own personal assistant. An eligible family member or friend may be able to serve in that role. A designated representative may direct care when appropriate under program rules. CDPAP can work well when someone trusted is willing and able to provide the authorized care, but it requires the responsibilities that come with directing it.

New York’s statewide CDPAP fiscal intermediary is Public Partnerships LLC (PPL). For questions about CDPAP registration or the fiscal intermediary, PPL’s number is 1-833-247-5346. The Medicaid office or managed care plan handles the applicable assessment and service authorization process.

When the need is urgent: request “Immediate Need”

If a Medicaid member urgently needs personal care or CDPAP services, use those words when contacting the responsible Medicaid office or plan:

“My parent is being discharged from the hospital and needs help with daily activities immediately. I want to request an Immediate Need assessment for personal care services or CDPAP. What must we submit today?”

New York has an expedited process for qualifying Immediate Need requests. It generally requires an Attestation of Immediate Need (DOH-5786) and a Practitioner Statement of Need (DOH-5779). Someone who still needs to apply for Medicaid, or for Medicaid coverage that includes community-based long-term care, may also need an application and supporting financial information. Ask the office handling the case for the complete document list.

If the person is not enrolled in a Medicaid managed care plan: Contact the county Local Department of Social Services, or HRA in New York City, about the Immediate Need request.

If the person is already enrolled in a Medicaid managed care or managed long-term care plan: Call the member services number on the plan card, explain the urgency, and ask the plan to arrange its expedited assessment and authorization process. New York has guidance for expedited assessments for managed care enrollees.

New York describes a 12-day decision timeline after all necessary information has been received in the applicable Immediate Need process. That is not a guarantee that an aide will arrive within 12 days. Keep copies of every form, ask when the request was considered complete, and get a reference number or written confirmation.

If your parent has both Medicare and Medicaid, pursue the services through their appropriate channels: ask the discharge team about qualifying Medicare skilled care and ask the Medicaid office or plan about urgently needed personal care or CDPAP. Medicaid can cover personal care benefits that Medicare normally does not.

What if care will be needed for months or years?

A hospital stay may reveal that a person’s needs are not temporary. Managed Long Term Care (MLTC) coordinates community-based long-term services for eligible New Yorkers. For many adults age 21 or older who have both Medicare and Medicaid and are assessed as needing community-based long-term services for more than 120 days, MLTC enrollment rules apply, subject to exclusions and other requirements. Different plan types include partial-capitation MLTC, Medicaid Advantage Plus, and PACE.

Assessment and eligibility rules matter. New York’s minimum needs requirements, applicable to relevant assessments beginning September 1, 2025, may affect eligibility for personal care, CDPAP, and certain MLTC plans. Describe the patient’s real needs, including needs during the night, and ask for the decision and care plan in writing.

For some people at risk of nursing-home placement, New York’s Nursing Home Transition and Diversion (NHTD) waiver may be worth discussing. There is also a separate Traumatic Brain Injury (TBI) waiver for eligible people. Each has its own criteria and service-planning process. Ask a discharge planner or care coordinator whether a referral is appropriate, while addressing any immediate gap in care through the applicable process.

Do not overlook appointments and transportation

A recovery plan may include a primary care visit, specialist follow-up, therapy, tests, and counseling. Before discharge, get a current medication list and ask which appointments have actually been scheduled.

If transportation is a barrier, ask about New York Medicaid’s non-emergency medical transportation benefit for eligible members. It is intended for trips to and from medical appointments and generally must be arranged ahead of time through the applicable transportation process.

The questions every family should answer before going home

Who will help on the first day and night? Name the person and the hours they can actually cover.

Which services have been accepted and scheduled? Confirm the first nursing, therapy, or aide visit.

Has an Immediate Need request been made if urgent personal care is required? Confirm who has the forms and whether anything is missing.

What rehabilitation is needed? Identify the therapy goal, provider, setting, and start date.

How is the patient coping emotionally? Ask whether social work or mental health follow-up is appropriate.

Are medications, equipment, and supplies ready? Confirm what has been ordered and when it will arrive.

How will the patient get to appointments? Arrange transportation if needed.

Who is the contact if a service does not start? Keep the hospital, plan, and provider numbers together.

What happens after the first few weeks? Ask whether the patient needs reassessment or a longer-term care plan.

An Immediate Need request begins an expedited review; it does not place a caregiver in the home that night. If the patient has no safe arrangement between discharge and the start of services, tell the discharge team plainly and ask them to address that gap before discharge.

The best plan begins with a simple question: What will this person need at home, starting the moment they arrive? Once that is clear, the family, hospital, clinicians, Medicaid office or plan, therapists, and caregivers can each take responsibility for the right part of recovery.

For information about Marton Care’s health care initiatives, visit. Service eligibility, authorization, hours, provider participation, and availability depend on the patient’s coverage and individual assessment.