After a Hospital Stay: Discharge Planning in Hampton Roads

How fast do Hampton Roads hospitals discharge older patients?

Fast: discharge planning at Sentara Norfolk General, Riverside Regional, Bon Secours Maryview or Chesapeake Regional often begins within a day or two of admission, and a family may hear the word "medically ready" before they have toured anywhere. The timeline is days, not weeks.

Ask the hospital case manager on day one what the likely discharge date is and what your parent will need afterward. Write down the name and phone number. If you disagree with a discharge date, say so promptly and ask what the appeal steps are. You will make better choices if you start before the day you are told to pack.

Bring someone with you if you can. Discharge conversations happen at the bedside while your parent is tired, medicated or confused, and a second person can take notes. Ask for every instruction in writing, including medication changes and follow-up appointments, and keep the papers together in one folder.

Is your parent admitted as an inpatient or under observation?

Ask directly, because the answer affects Medicare. Medicare Part A covers skilled nursing facility care only after a qualifying inpatient hospital stay of at least three days, and observation days do not count toward those three days. A parent can spend two nights in a hospital bed and still be an outpatient.

Status can change during a stay, so ask each day. If the stay is under observation, rehab in a skilled nursing facility may not be covered by Medicare, and that changes the plan. Read what Medicare covers before you agree to any facility.

What is the skilled nursing referral list and how should you use it?

The hospital case manager will usually give you a list of skilled nursing facilities (SNFs) that have beds and accept your parent's insurance. Use it as a starting point, not a verdict. You may choose among them, and a bed that is open today may be gone tomorrow.

Medicare covers up to 100 days of skilled nursing care per benefit period after a qualifying stay. Days 1 through 20 have no coinsurance, and days 21 through 100 cost $217 a day in 2026. Look up your short list on federal Care Compare, which rates nursing homes, and ask the case manager about each. See nursing home star ratings.

What screening comes before long-term care at home or in a facility?

Medicaid long-term services start with a screening done by a hospital team if the person is in the hospital, or the local team if not. The Uniform Assessment Instrument (UAI) is used for assisted living admission. Ask the case manager which screening applies to your parent and who files it.

If your parent may need the Commonwealth Coordinated Care Plus (CCC Plus) Waiver to pay for care at home, the person must also be enrolled in Medicaid. Starting the application during the hospital stay can save weeks. See the CCC Plus Waiver guide and how the UAI works.

Can your parent go straight to assisted living from the hospital?

Sometimes, but not if the needs are too high. A Virginia assisted living facility cannot admit someone who needs a ventilator, a nasogastric tube, continuous licensed nursing care, or isolation for an airborne infection. It also cannot take most stage III or IV pressure ulcers.

Admission also requires a UAI, a physical examination report and a documented interview, which takes time. Many families use a short skilled nursing stay first, then move to assisted living once the hospital paperwork and the facility's own assessment are done. Ask a community whether it can do that assessment in the hospital and how soon it can hold an apartment. See admission limits.

What should families do in the first 48 hours?

Pick a point person, gather medication lists and insurance cards, and call two or three communities or SNFs on the list. Ask each about bed availability, what it needs from the hospital, and whether it accepts the payer. Take notes on every call.

If a spouse is at home alone, ask the hospital social worker about their needs too. If you want help with a shortlist, we can match your parent's needs to communities in Norfolk, Virginia Beach, Chesapeake or the Peninsula, and we are paid by communities when a referred family moves in. Browse nursing homes and assisted living in the meantime.

Also ask about transportation. A parent leaving Sentara Norfolk General for a facility in Chesapeake, or Riverside Regional for one across the James River, may need wheelchair transport booked in advance. Confirm who arranges it and whether the facility can receive a new resident in the evening.