One day, your parent is living at home.
Then there is a fall.
A stroke.
A heart attack.
An infection.
A surgery.
A sudden change in memory or mobility.
And within days, your family can find itself facing a question you never expected to answer:
“Where is Mom or Dad going to live now?”
The hospital may tell you that your loved one is medically ready for discharge — but you know they cannot safely return home.
Maybe they can no longer walk independently.
Maybe they need help getting to the bathroom.
Maybe they need medications managed throughout the day.
Maybe they are confused, weak, or at risk of falling.
Maybe you simply know that the level of care they now require is more than your family can safely provide.
If this is happening to you, you do not need to understand the entire long-term-care system overnight.
You need to answer a few questions in the right order:
What care does my loved one need?
What will insurance or benefits pay for?
What type of setting can provide that care?
And how do I actually find one?
This guide walks you through those steps.
Download the Hospital-to-Care Checklist
Need the steps in one place?
Download our free one-page checklist to help you work through discharge planning, care needs, insurance, care options, provider calls, tours, and what to gather before leaving the hospital.
Step 1: Ask the Hospital Who Is Handling Discharge Planning
Before you start searching the internet on your own, ask the hospital:
“Who is handling discharge planning for my loved one?”
Depending on the hospital, you may work with a discharge planner, case manager, social worker, nurse, or another member of the care team.
Ask to speak with that person as early as possible.
Tell them clearly:
“My loved one cannot safely return home. We need help understanding the next level of care.”
Ask:
• What level of care does the medical team believe they need after discharge?
• Do they need rehabilitation or skilled nursing first?
• Could they safely live in a residential care setting?
• What help will they need with bathing, dressing, toileting, medications, mobility, or transfers?
• Will they need nursing services?
• What equipment will they need?
• Who can provide us with the discharge plan and medication list?
• Who should we contact if we disagree with or don’t understand the discharge plan?
Do not be afraid to say:
“I don’t understand what I’m supposed to do next.”
You are not expected to already know how the long-term-care system works.
Medicare provides a free Your Discharge Planning Checklist for patients and caregivers. It can help you work through questions about medications, equipment, follow-up care, where care will happen after discharge, and other important next steps.
Step 2: Find Out Exactly What Care Your Loved One Needs
Before searching for a facility or care home, understand what you’re actually looking for.
Ask the hospital team to explain your loved one’s needs in plain language.
Can they:
• Walk independently?
• Transfer from bed to chair?
• Use the bathroom independently?
• Bathe and dress themselves?
• Eat independently?
• Manage medications?
• Be left alone safely?
• Recognize people and surroundings?
• Communicate their needs?
• Sleep safely without overnight assistance?
Also ask whether they need:
• Physical therapy
• Occupational therapy
• Speech therapy
• Wound care
• Oxygen
• Medication management
• Nursing services
• Dementia support
• Two-person transfers
• Hospice or palliative care
• Specialized medical equipment
Write this information down.
When you begin calling providers, this is what will help them determine whether they can safely meet your loved one’s needs.
Step 3: Check Medicare, Medicaid and Other Insurance
Next, figure out how care may be paid for.
Start by identifying exactly what coverage your loved one has.
Look for:
• Medicare
• Medicare Advantage
• Medicaid
• Private health insurance
• Long-term care insurance
• Veterans benefits
• Other supplemental coverage
If you’re unsure, ask the hospital’s case manager, social worker, or discharge planner to help you identify the coverage information on file.
If Your Loved One Has Medicare
Medicare may cover qualifying short-term skilled nursing facility care when specific requirements are met.
That can be important when someone needs rehabilitation or skilled nursing after hospitalization.
But Medicare generally does not pay indefinitely for residential long-term care simply because someone can no longer live independently.
Ask:
“Does my loved one qualify for Medicare-covered skilled nursing or rehabilitation after this hospital stay?”
If they do, also ask:
“What happens when that coverage ends?”
That second question matters.
Rehabilitation may be the next stop, but it may not be the final living arrangement.
Review Medicare’s official Skilled Nursing Facility Care Coverage page to understand current eligibility and coverage requirements.
If Your Loved One Has Medicaid
Medicaid can help eligible individuals pay for long-term services and supports.
Depending on the person’s eligibility, care needs, state, program, and provider, Medicaid-supported services may be available at home or in certain residential care settings.
Do not assume every care home or facility accepts Medicaid.
Ask individual providers about participation.
You can also review the federal government’s Medicaid Long-Term Services & Supports information to understand how Medicaid can support long-term care.
If Your Loved One Is Private Pay
Private pay generally means your loved one will use personal financial resources to pay for care.
That may include:
• Savings
• Retirement income
• Social Security
• Pension income
• Long-term care insurance
• Veterans benefits for those who qualify
• Other assets or resources
Even if your loved one can currently private pay, ask what happens if those resources eventually decrease.
That question can prevent another crisis later.
Related Ovella Resource: Medicare vs. Medicaid: What’s the Difference — and Which One Pays for Long-Term Care?
Step 4: Determine Whether This Is Short-Term Rehabilitation or Long-Term Care
This distinction can completely change your search.
Your loved one may need short-term skilled nursing or rehabilitation before anyone knows whether they can safely return home.
For example, someone recovering from surgery, a stroke, serious illness, or hospitalization may temporarily need:
• Physical therapy
• Occupational therapy
• Skilled nursing
• Rehabilitation
• Medical monitoring
After rehabilitation, they may improve enough to return home.
Or the rehabilitation team may determine that living independently is no longer safe.
At that point, the family may need to consider long-term residential care.
Ask:
“Are we choosing a temporary rehabilitation facility, or are we choosing where my loved one may live long term?”
Those are very different decisions.
If skilled nursing is being recommended, Medicare’s Skilled Nursing Facility Care Coverage page can help you understand what Medicare may cover and under what circumstances.
Step 5: Understand the Main Long-Term Care Options
If returning home is not safe, there isn’t just one alternative.
Depending on your loved one’s needs, options may include:
Adult Family Home — Washington
An adult family home is a smaller licensed residential home where adults receive housing, personal care, supervision, and other services.
These homes generally have fewer residents and can provide a more residential, home-like environment.
Adult Foster Home — Oregon
Oregon uses the term adult foster home for a smaller licensed residential care setting.
For families near the Washington-Oregon border, an easy way to remember it is:
Washington = Adult Family Home
Oregon = Adult Foster Home
Assisted Living
Assisted living communities are generally larger and may offer private rooms or apartments, common spaces, activities, meals, and assistance with daily living.
Memory Care
Memory care provides specialized support for people living with dementia or other cognitive impairment.
Memory support may be available in different types of residential settings, so a dementia diagnosis does not automatically mean someone must move into a large dedicated memory-care facility.
Skilled Nursing or Nursing Home Care
Skilled nursing facilities provide a higher level of nursing and medical care.
Some stays are temporary for rehabilitation.
Others involve long-term nursing care.
The right category depends on the person’s actual care needs — not simply their age.
Related Ovella Resource: Adult Family Home vs. Assisted Living vs. Nursing Home: What’s the Difference?
Step 6: If You’re in Washington, Start Here
If you’re overwhelmed and don’t know where to begin, Washington has public resources specifically designed to help families understand long-term services and supports.
Washington Community Living Connections and Local Long-Term Care Resources can help Washington residents learn about services and connect with local assistance.
Community Living Connections: 1-855-587-0252
Your local Area Agency on Aging can also help older adults and families understand services and programs available in their community.
If your loved one is currently in the hospital and may need Medicaid-funded long-term care, Washington DSHS also provides information about Inpatient Hospital Assessments and Transitions.
This is particularly relevant for families trying to understand Medicaid long-term-care eligibility, assessments, and transitions from the hospital to another care setting.
You do not need to know exactly which program your loved one needs before reaching out.
Tell them:
“My loved one is in the hospital and cannot safely return home. I need help understanding long-term-care options and whether they may qualify for assistance.”
Step 7: If You’re in Oregon, Start Here
Oregon families can contact the Aging and Disability Resource Connection of Oregon (ADRC).
ADRC helps people understand long-term-care options and find services and resources.
Oregon ADRC: 855-673-2372
Oregon’s long-term-care resources can also help families understand different care settings and how Medicaid long-term-care services work.
If you feel like you’re starting from zero, this can be one of your first calls.
Tell them:
“My loved one is being discharged from the hospital and cannot safely return home. I need help understanding what long-term-care options are available.”
Step 8: Start Searching for Actual Providers
Once you understand approximately what level of care your loved one needs, begin looking at individual providers.
Do not search only for:
“nursing home near me.”
Your loved one may not need a nursing home.
Depending on their needs, they may be appropriately supported in an adult family home, adult foster home, assisted living community, memory-care setting, or another type of care.
When comparing providers, look at:
• Location
• Type of care
• Services
• Experience
• Specialties
• Photos
• Reviews
• Availability
• Payment options
Then start calling.
Ovella Living helps families search and compare residential care providers so they can better understand their options before contacting and touring homes.
Step 9: Call Providers and Explain the Care Needs Clearly
When you call a provider, you don’t need to know all the medical terminology.
You do need to explain what you know.
You might say:
“My dad is being discharged from the hospital after a stroke. He can’t safely return home. He needs help transferring, bathing, dressing, medications, and getting to the bathroom. We’re trying to determine whether your home could meet his needs.”
Then ask:
• Do you have an opening?
• Can you meet these care needs?
• What additional information do you need?
• Do you need an assessment before accepting him?
• What is the monthly cost?
• What is included?
• Do you accept Medicaid, if applicable?
• When could we tour?
You may have to call several providers.
That is normal.
The goal isn’t simply to find the first available bed.
It’s to find an available provider who can safely meet your loved one’s needs.
Step 10: Tour Before Making a Decision Whenever Possible
If circumstances allow, tour the home or facility before agreeing to placement.
Pay attention to more than décor.
Watch:
• How caregivers interact with residents
• Whether residents appear comfortable
• Cleanliness
• Staffing
• Safety
• The available bedroom
• Common areas
• Meals and dining
• Outdoor spaces
• The overall atmosphere
Ask who will actually care for your loved one.
Ask how families are kept informed.
Ask what happens overnight.
Ask what happens if your loved one’s needs increase.
Ask about costs.
And keep asking questions when something isn’t clear.
Related Ovella Resource: Red Flags to Watch for When Touring a Care Home
Step 11: Ask What Happens if the Money Runs Out
This question may feel premature.
Ask it anyway.
If your loved one is private pay, ask:
“If my parent eventually qualifies for Medicaid, do you participate in Medicaid, and could they potentially remain here?”
The answer may affect your decision.
A care setting that works financially for six months but requires another move when savings decline may not be the best long-term choice.
Understanding this before admission gives your family more information to plan ahead.
Related Ovella Resource: What Happens When a Parent Runs Out of Money for Long-Term Care?
Step 12: Before Leaving the Hospital, Get the Information You’ll Need
Before your loved one leaves the hospital, make sure you understand:
• Current medications and dosages
• Medication changes made during hospitalization
• Follow-up appointments
• Therapy recommendations
• Mobility restrictions
• Dietary instructions
• Wound-care instructions, if applicable
• Equipment needs
• Warning signs or complications to watch for
• Who to call with medical questions
• Where prescriptions will be sent
• Transportation arrangements
• The written discharge plan
Keep this information together.
The next provider will need accurate information to continue your loved one’s care safely.
Before leaving, consider going through Medicare’s Your Discharge Planning Checklist one more time.
Your “I Don’t Know Where to Start” Checklist
If everything above feels overwhelming, start here:
1. Ask the hospital: “Who is handling discharge planning?”
2. Ask: “What level of care does my loved one need when they leave?”
3. Write down their current care needs.
4. Identify Medicare, Medicaid, private insurance, long-term care insurance, and other benefits.
5. Ask whether short-term rehabilitation is appropriate.
6. If long-term care is needed, determine which types of residential care could safely meet their needs.
7. Contact your state’s public aging and long-term-care resource agency.
8. Search for providers that match those needs.
9. Call several providers and ask about care capabilities, availability, and cost.
10. Tour appropriate homes whenever possible.
11. Ask what happens if care needs or finances change later.
12. Get the complete discharge and medication information before leaving the hospital.
You do not have to solve everything at once.
Just find the answer to the next question.
Frequently Asked Questions
What happens if an elderly parent is discharged from the hospital but can’t live alone?
The next step depends on their medical and personal-care needs. They may need short-term rehabilitation, home health and in-home support, an adult family or foster home, assisted living, memory care, or skilled nursing. Ask the hospital team what level of care they believe is necessary after discharge.
Will the hospital help me find somewhere for my parent to go?
Ask the hospital who is responsible for discharge planning for your loved one. A discharge planner, social worker, case manager, nurse, or other team member may help explain post-hospital care needs and appropriate options.
Does Medicare pay for somewhere to live after the hospital?
Medicare may cover qualifying skilled nursing facility care after hospitalization when applicable requirements are met. Medicare generally does not pay for ongoing custodial residential long-term care simply because someone can no longer live independently.
What if my parent can’t afford long-term care?
Medicaid may help eligible individuals pay for long-term services and supports. Eligibility and available services vary, so begin researching options before private resources are exhausted.
What if my parent needs rehabilitation first?
A skilled nursing or rehabilitation stay may be appropriate before making a permanent long-term-care decision. Ask whether the medical team expects the person to regain enough function to return home or whether long-term residential care is likely to be needed afterward.
How quickly should I start looking for long-term care?
As soon as the hospital indicates that returning home may not be safe. Understanding care needs, insurance, finances, and available providers takes time, so starting discharge planning early gives your family more options.
The Bottom Line
A sudden hospitalization can change a family’s life in days.
You may go from believing your parent is going home to suddenly being asked:
“Where will they go next?”
You don’t need to know the entire senior-care system.
Start with the care needs.
Understand the insurance and finances.
Use the public resources available to you.
Learn which type of care is appropriate.
Then compare individual providers.
The goal isn’t simply to get your loved one out of the hospital.
It’s to find the safest, most appropriate next step — and, when long-term care is needed, a place where they can continue to be cared for with dignity.
DOWNLOAD THE FREE HOSPITAL-TO-CARE CHECKLIST
Ovella Living helps families explore residential care options, compare providers, and find care when they don’t know where to begin.
This article is for general educational purposes and is not medical, legal, financial, insurance, or benefits advice. Coverage, eligibility, discharge requirements, and long-term-care programs vary by individual circumstances and may change. Confirm your loved one’s discharge plan with their healthcare team and verify current benefit and program information with the appropriate insurer or government agency.
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