I Am a Former Home Health COO — Here’s What I’d Ask If I Were Being Discharged from a Hospital

By Brett Frankenberg | Concierge Health Advocate

After spending over 30 years in post-acute care — and helping thousands of families navigate hospital discharges — I’ve seen just how fragile that moment can be.

The truth? Most people walk out of the hospital with more questions than answers — and that confusion often leads to avoidable readmissions, medication errors, or missed follow-ups.

If I were being discharged from a hospital tomorrow, here are the exact questions I’d ask — not because I’m a professional, but because I’ve seen what happens when these are not asked.

🪜 “Who’s actually coordinating my care after I leave?”

This is the question that reveals everything. Most people assume someone is in charge — a case manager, a doctor, a nurse. But the reality is, care coordination often stops the minute you leave the building unless someone takes the lead.

I’d want to know: - Who will follow up on my recovery plan? - What provider is overseeing my next steps? - Will someone contact my primary care doctor?

💰 “What services am I eligible for — and who’s arranging them?”

Medicare covers certain home health services, but only if specific criteria are met. Don’t assume anything is automatic.

I’d ask: - Am I eligible for home health services? (Nursing, PT, OT?) - Who chooses the agency — me or the hospital? - When will they contact me?

🕜 “When is my first follow-up — and who scheduled it?”

A delayed follow-up visit is one of the most common reasons people bounce back to the ER. Ideally, a follow-up appointment should be scheduled before you leave the hospital.

Ask: - Do I have a scheduled follow-up? (With name, time, location?) - What labs or imaging do I need before that? - Who do I call if I need to reschedule?

🍆 “Can you walk me through every medication I’ll be taking — and why?”

Medication errors happen every day after discharge. Changes are made in the hospital, and patients often don’t know what’s new, what’s stopped, or what’s doubled.

Ask your nurse or doctor: - What’s changed from before my admission? - Are there any interactions I should know about? - What should I do if a prescription is delayed at the pharmacy?

⚠️ “What are the red flags — and who do I call if they happen?”

Every condition has warning signs that indicate something’s going wrong. Don’t leave the hospital without knowing what to look for.

Ask: - What are signs of infection or complication? - At what point should I call the doctor — or go back to the ER? - Who can I call after hours if I have concerns?

🌐 “Do I have everything I need to safely recover at home?”

Think practically: - Equipment (walker, oxygen, hospital bed)? - Written instructions for care, wound care, diet? - Family or caregiver support arranged?

The hospital team might assume you have these things in place — don’t let them guess.

Final Thought

Hospital discharges can feel rushed, confusing, and overwhelming. But asking the right questions can make the difference between a smooth recovery — and a return to the ER.

If you’re not sure what to ask, advocate for yourself. Better yet, bring someone who knows the system.

Because the truth is: it’s not just about getting out of the hospital. It’s about staying out.

Need help reviewing a discharge plan or coordinating follow-up care?
I offer private strategy calls for families managing complex transitions.

Book a consult: https://calendly.apexhealthadvocates.com
Apex Health Advocates
Concierge Health Advocacy for Life's Most Important Decisions