Leaving Lehigh Valley Hospital or St. Luke's: A Discharge Checklist for Families

The Lehigh Valley's hospitals

Two networks run nearly every hospital in the three counties: Lehigh Valley Health Network, now part of Jefferson Health, anchored by Lehigh Valley Hospital–Cedar Crest, and St. Luke's University Health Network, anchored by St. Luke's University Hospital in Bethlehem. Their case managers handle thousands of discharges to rehab, home and personal care homes each year.

Discharges move quickly. The day a doctor says your parent is medically ready, a case manager may already be calling nursing homes.

Step one: inpatient or observation

Ask whether your parent was formally admitted as an inpatient. Observation status, even for several nights, does not count toward Medicare's three-day requirement for skilled nursing coverage. If your parent needs rehab, this single question can be worth thousands of dollars.

Step two: what level of care

Ask the team whether they recommend skilled nursing rehab, home with home health, home with private help, or a personal care home. Ask why. If you disagree, say so; you can ask for a family meeting and you can appeal a Medicare discharge you think is premature.

If your parent was living alone and fell, the recommendation is often rehab first and then a decision about where to live.

Step three: choosing a rehab

Ask for the list of nursing homes with open beds and look each one up. CMS data for the 30 certified homes in the three counties shows star ratings, staffing hours and the latest inspection. You do not have to accept the first bed offered, and proximity to the family who will visit matters.

Ask whether the home accepts your parent's Medicare Advantage plan and whether prior authorization has been granted.

Step four: going home safely

If your parent is going home, ask the hospital to order home health, which Medicare covers for homebound patients, and arrange equipment such as a walker, shower chair or raised toilet seat before the ride home. Plan for someone to stay the first nights.

The county Area Agency on Aging can begin an assessment for in-home services, though waiting lists are common.

Paperwork to collect before leaving

Before your parent leaves, collect the discharge summary, the updated medication list with any stopped or new drugs, follow-up appointments, therapy orders and the contact name of the case manager. If your parent is going to a personal care home, the home will need the medical evaluation and medication orders before admission.

Check the medication list carefully against what is at home. Discharge is one of the most common points for medication errors, and a pharmacist can review the list if anything is unclear.

If you disagree with the discharge

Medicare patients receive a written notice of their discharge rights. If you believe your parent is being discharged too soon, you can request a review by Medicare's quality improvement organization, usually by noon of the planned discharge day, and the hospital generally cannot charge for the extra days while the review is pending.

Ask the case manager for the notice and the phone number. A calm, documented request is usually more effective than an argument at the bedside.

Medicare Advantage and prior authorization

Many Lehigh Valley seniors have Medicare Advantage plans, which often waive the three-day hospital rule but require prior authorization for rehab. Delays in authorization are one of the most common reasons a discharge stalls. Ask the case manager each day whether the request has been sent and approved.

If the plan denies rehab, you can ask for an expedited appeal. A PA MEDI counselor at your county's Area Agency on Aging can explain the plan's appeal rights.

Step five: start the next search early

If a personal care home may be the long-term answer, begin looking during rehab. Homes will need a medical evaluation within 60 days before admission, and those with dementia units or private rooms may have waiting lists.

Our directory lets you filter licensed homes by town and see each one's latest DHS inspection.