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Guide · California

Discharge planning checklist

What to settle before leaving a hospital or a facility, so the next step is ready when the patient arrives. Built from Medicare's own discharge checklist and the federal rules hospitals follow.

Last reviewed October 2, 2026. Facts are linked to the official sources listed at the end of the page.

Your part in discharge planning

Under federal rules, a hospital's discharge planning has to focus on the patient's goals and treatment preferences, and include the patient and their caregivers or support people as active partners.1 When care after the hospital is part of the plan:

  • The hospital must give a list of available Medicare-participating home health agencies, skilled nursing facilities, inpatient rehabilitation facilities or long-term care hospitals, as fits the patient's needs.1
  • The hospital must tell the patient or their representative that they are free to choose among those providers, and it must not limit which qualified providers are available to them.1
  • Patients in a managed care plan, such as a Medicare Advantage plan, need to check with their plan which providers are in its network.1
  • The hospital's discharge plan must identify any home health agency or skilled nursing facility the patient is referred to in which the hospital has a disclosable financial interest, or that has one in the hospital.1

Inpatient or observation? Ask every day

A patient can be in a hospital bed and still be an outpatient: observation services are outpatient services, given while the doctor decides whether to admit the patient or send them home.3 Status matters for costs, and for skilled nursing coverage: under Original Medicare, time under observation or in the emergency room before admission does not count toward the three-day inpatient stay needed for skilled nursing facility coverage.4

  • A patient who receives observation services for more than 24 hours should get a written notice called the Medicare Outpatient Observation Notice (MOON).3
  • Since February 14, 2025, a patient with Medicare who was admitted as an inpatient and then changed to outpatient observation may be able to ask for a fast appeal. Eligible patients should receive a Medicare Change of Status Notice (CMS-10868) before leaving, which explains the right to appeal.5

Before the discharge date

Go through these with the care team, the hospital social worker or case manager, and the people who will help at home. Write the answers down.

Where and when

  • Where will care happen after discharge, and what are the options (for example, home with home health, a skilled nursing facility, or inpatient rehab)?2
  • What is the planned discharge date and time, and who will be there to receive the patient?
  • How will the patient get there, and does the trip need a wheelchair or other help?

Equipment and the home

  • What medical equipment is needed, is it covered, and who delivers it, before the patient arrives?2
  • Is the patient ready for daily activities such as bathing, cooking or getting around, and what help is needed?2
  • Is the home ready: stairs, bathroom access, a place to sleep on one level if needed? Ask the care team what they recommend.

Medications

  • A complete list of every medication, including over-the-counter drugs, vitamins and supplements, reviewed with the staff: which to continue, and at what dose.2
  • Prescriptions filled and other errands done before discharge.2

Follow-up and questions

  • Names and phone numbers of the people to call with questions or concerns.2
  • What problems to watch for, and what to do if they happen.2
  • Which follow-up appointments are scheduled, with whom, and when.
  • Written discharge instructions you can read and understand, and a summary of current health status.2

Costs

  • What the plan covers and what the out-of-pocket costs will be. Ask the social worker or the health plan.2

Support at arrival

  • Can the caregiver provide the help that is needed, and what training or support do they need first?2
  • Ask the staff to show any special care tasks, and practice them before discharge.2
  • If coping is a concern, talk with the social worker and ask about support groups.2

Family caregivers can find more help in the Family Caregiver Guide.

If the discharge feels too soon

Hospital patients with Medicare should receive a notice called "An Important Message from Medicare about Your Rights" within two days of admission and before discharge.6 A patient who believes they are being discharged too soon can ask for a fast appeal by following the directions on that notice no later than the scheduled discharge day. If they ask in time, they won't have to pay for the stay while they wait for the decision, except for any coinsurance or deductibles.6

When covered skilled nursing, home health or hospice services are ending, the patient should get a "Notice of Medicare Non-Coverage" at least two days before, and may have the right to a fast appeal.6

Fast appeals for Medicare patients in California go to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Its toll-free line is 1-877-588-1123.7

Sources

Official government pages, each read on October 2, 2026. Links open in a new tab. Prime Care Link is not affiliated with these agencies.

  1. 1.Code of Federal Regulations — 42 CFR 482.43, Condition of participation: Discharge planning
  2. 2.Medicare.gov — Your discharge planning checklist (CMS Product No. 11376, December 2025)
  3. 3.Medicare.gov — Inpatient or outpatient hospital status affects your costs
  4. 4.Medicare.gov — Skilled nursing facility care
  5. 5.Medicare.gov — Appeal when a hospital changes your status from inpatient to outpatient getting observation services
  6. 6.Medicare.gov — Fast appeals
  7. 7.Centers for Medicare & Medicaid Services — BFCC-QIO contact directory (California)

Want help with your situation?

We help families and professionals sort through care options and keep the next step moving. Our navigation support is offered at no cost to families and the professionals who refer them, and providers pay nothing to be included or recommended. Call (818) 574-3333 on weekdays or send us a message.