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Hospital to nursing home: discharge planning done right

Many nursing-home placements begin with a phone call from a hospital discharge planner: your parent is ready to leave, and you have a day to pick a rehab facility. It’s the worst possible time to make a good decision — and knowing your rights slows it down enough to choose well.

You have more time and choice than you’re told

Hospitals must provide safe discharge planning and give you a choice of facilities — they can’t force you into one. If you feel a discharge is unsafe or too fast, you can request the planner slow down. And if your parent has Original Medicare, the discharge itself can be appealed — which is the one thing on this page that actually stops the clock. It has a name, a phone number, and a deadline, so here they are.

The fast appeal, concretely

The notice. Within two days of an inpatient admission, the hospital must give the patient a form called “An Important Message from Medicare About Your Rights” — staff call it the IM or IMM. Someone signs it and it disappears into a folder. It is the document that explains this appeal, and it lists the phone number you need. If you can’t find it, ask any nurse or the hospital’s patient-advocate or case-management office for “a copy of the Important Message from Medicare.” They must give you one; you should also get a copy again before discharge.

Who takes the appeal. Not the hospital. An independent outside reviewer called a BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization). There is one for each state, and its number is on the IM. If you don’t have the notice in your hand, call 1-800-MEDICARE (1-800-633-4227) and ask for your state’s BFCC-QIO. You do not need a lawyer, you do not need the hospital’s permission, and it costs nothing. A phone call is enough — it does not have to be in writing.

The deadline. Request the review no later than the day of discharge (42 CFR § 405.1206). Don’t cut it fine: call the moment you disagree, not the morning the bed is needed. If you miss it and stay anyway, you can be billed for the days after the discharge date.

What it buys you. This is the part worth knowing at 9pm. If you request the review in time, your parent stays put while the QIO decides, and they are not financially responsible for the hospital stay (beyond any coinsurance and deductible they’d owe anyway) until at least noon of the day after the QIO’s decision reaches you. In plain terms: filing freezes both the discharge and the meter, and the review is fast — typically about a day. Even a decision that goes against you has usually bought you the time to vet facilities properly instead of taking the first bed offered.

Two honest caveats. This is the hospital appeal. When it’s a skilled-nursing stay, home health, or hospice being cut off rather than a hospital discharge, it’s a different notice (a Notice of Medicare Non-Coverage) with a different and tighter deadline — by noon of the day after you get the notice (42 CFR § 405.1202). And Medicare Advantage plans run their own appeal process, so if your parent has an Advantage plan, the plan’s number is the one to call. Your free SHIP counselor will walk you through either one at no cost.

Ask the discharge planner

What level of care does my parent actually need — skilled rehab, or long-term? Which nearby facilities have a bed and accept our coverage? Are you steering us to a facility your system owns or partners with? (It happens — ask directly.) Get the list, then vet it yourself.

Vet the options fast

Even with one day, you can pull each facility’s CMS inspection record, check the health-inspection star and staffing, and rule out any with a Special Focus flag or harm-level pattern. The compare tool puts the finalists side by side in minutes.

One thing to look at that most families miss: CMS rates quality measures separately for long-stay and short-stay residents, and every facility page here shows both. You are shopping for a short stay — rehab, post-hospital, home in a few weeks. The short-stay star is the one about people in your parent’s situation; the long-stay star is about people who live there permanently, and a home can be good at one and ordinary at the other. Read the short-stay line first. (Both are built from data the home reports about itself, so weigh them against the inspection record, which isn’t.)

The rehab numbers, on every facility page

The star is a summary. Underneath it, each nursing-home page on this site carries a section called “Short-stay rehab — if you are coming here from a hospital”, and it is the part written for the situation you are in right now. It answers, with public data rather than a sales line, two of the questions further down this page that families are otherwise left to ask a stranger on the phone.

“Do people get home from here?” CMS publishes a discharge-to-community rate — the share of Medicare patients leaving this home who got back to the community and stayed there for at least 31 days, rather than bouncing back to a hospital. We show it as “Got home and stayed home,” with CMS’s own risk-adjusted verdict on whether the home is better than, worse than, or no different from the national rate. This is the one measure on the panel that regularly separates homes: of the homes CMS rates on it, roughly a third land clearly on one side or the other. The companion readmission measure almost never does — about 97% of rated homes come back “no different from the national rate,” so a home passing that test has cleared a very low bar and you should not read it as praise. Two honest limits: CMS gives no rate at all for about a fifth of homes (small or new rehab programs), in which case the page says not reported rather than inventing a number; and this measure covers October 2022 through September 2024. That window closed well over a year ago. It describes the building as it was staffed and run then, which is a real thing to know and is not the same as a fact about the building this week — every page states the period the measure covers, per measure, because they differ.

“Is there actually therapy in this building?” Homes file their hours worked to CMS through payroll — not a survey, not a brochure — and we show the physical, occupational and speech therapist hours out of it, which matters if you are choosing for a stroke rather than a hip, because the three are not interchangeable. Read it with the caveat the page states plainly: the figure is therapy hours per resident in the building, not per rehab patient. CMS does not publish minutes per patient and neither does anyone else. A home with a small rehab wing inside a large population of permanent residents reads low even when its rehab patients get plenty of therapy. It compares homes doing similar work; it is not a score. And a home that filed no therapist hours reads not reported, never 0.00 — hundreds of homes that plainly do deliver therapy simply did not file, and printing a zero about them would be a false statement, not a cautious one.

None of this replaces the phone call. It changes what you say on it: you arrive already knowing which questions this particular building has a weak answer to, which is the whole difference between vetting a list and being handed one. Pull the finalists up on the near-me search or put them side by side in the compare tool, then read that section on each.

The questions a rehab family should actually ask

The generic tour questions are for a permanent move. For a rehab stay, therapy is the product, and these get at whether there is any. On two of them, the facility page here gives you a partial answer before you dial — noted below:

Know what Medicare covers

If this is post-hospital rehab, it may fall under the Medicare 100-day benefit — understand the 3-day rule and when coverage ends, so a “covered” stay doesn’t turn into a surprise bill or a scramble to arrange long-term payment. Coverage does not depend on your parent continuing to improve, whatever anyone tells you later.

If there's a mental-health or intellectual-disability diagnosis: PASRR

This is the step nobody mentions until it stops you, and it is the reason some placements that looked settled suddenly aren’t.

Before a Medicaid-certified nursing facility can admit anyone, federal law requires a screening called PASRR (Preadmission Screening and Resident Review). Everyone gets a Level I screen — a short form, usually invisible to the family. But if the Level I flags a suspected serious mental illness or intellectual disability, it triggers a Level II evaluation: a fuller assessment, run by the state’s mental-health or disability authority rather than by the hospital or the nursing home, that decides two things. Whether a nursing facility is the right setting at all, and whether the person needs specialized services the facility must then arrange.

The point families miss: a Level II is not the nursing home’s decision, and the nursing home cannot skip it or hurry it. It is a separate state process on its own timeline, and admission genuinely cannot proceed without it. So a hospital can tell you a bed is ready, the facility can say yes, and the admission still stalls — sometimes for days, occasionally longer — on a screening nobody named for you.

What to do with this: if your parent has a psychiatric diagnosis, a dementia diagnosis that sits alongside one, or an intellectual or developmental disability, ask the discharge planner on day one: “has a PASRR Level I been done, and is a Level II going to be required?” Asking early is the whole trick — the process can often run in parallel with everything else on this page instead of after it. Ask, too, what the Level II concluded about specialized services, because that answer becomes the facility’s obligation once your parent is in the door. The screening isn’t an obstacle to argue with; it is a protection, and it exists precisely because nursing homes were once used as a default destination for people who didn’t need to be there. But it only protects you on time if you know it’s coming.

PASRR requirements are set at 42 CFR §§ 483.100–138; the Level I / Level II structure and the evaluation criteria are at § 483.128 ↗. Your state’s process, forms, and timelines are its own — the discharge planner, the Long-Term Care Ombudsman, or your state Medicaid agency can tell you how yours runs.

Before you sign the admission paperwork

The last step of a rushed discharge is a stack of admission documents, handed to whoever is standing there. That stack is a contract — it may ask you to sign as “responsible party,” and it may include a binding arbitration clause. Both are worth understanding before you sign, and neither is something a certified facility can force on you as the price of a bed. Don’t let the speed of the discharge carry through to that signature: see what’s in an admission agreement.

This guide is general information, not medical, legal, or financial advice. Rules vary by state and change over time. For personalized, unbiased help, your Area Agency on Aging and your state’s Long-Term Care Ombudsman are free.