After Hospital Care in New York: A Family Care Guide

After hospital care means the help a person needs once they leave the hospital. For some families, that is a nurse who visits for a few weeks. For others, it is an aide who helps with bathing, meals, and walking. Some people go to a rehab center or nursing facility first.

Your first step is simple. Ask the hospital discharge planner what care your relative needs and who will arrange it. Do this before the day of discharge. Then decide who will cover each task at home: your family, an aide, or a nurse or therapist.

This guide is for New York families. It explains your choices, what to ask the hospital, how payment works, and what Cottage Home Care can and cannot do. The discharge team gives the medical instructions for your relative. Follow those first.

What after hospital care means

The hospital treats the illness or injury. After that, many people still need help. They may feel weak, take new medicines, or need a walker. They may not manage the stairs or the shower alone.

You may hear several names for this help: post-hospital care, transitional care, or post-acute care. People do not always use these names the same way. Ask the hospital what each service includes.

Three kinds of care, compared

Many people use more than one kind of care. Here is how they differ.

Not all rehab is the same. Ask the care team which level your relative needs. If you are looking at facilities, the hospital will have a list of local ones.

Before your relative leaves the hospital

Ask these questions while your relative is still in the hospital. Write down the answers.

• Who is our contact for questions after discharge? Get a name and a phone number.
• Where will care happen after discharge, and what are our options?
• What is the full medicine list? Which medicines are new, changed, or stopped?
• Which follow-up visits are booked? Write down the dates, times, and addresses.
• What equipment is needed, such as a walker, shower chair, or hospital bed? Who orders it, and when will it arrive?
• Does anyone need training for a task, such as changing a bandage? Ask the team to show you, then practice.
• Is a doctor ordering home health care? If so, ask for the list of agencies in your area and the date of the first visit.
• Was my relative admitted as an inpatient, or was this observation? How many inpatient days were there?

Ask for written discharge instructions that you can read and understand. If a medicine on the list does not match the bottles at home, ask the discharge nurse, the doctor, or a pharmacist. Do not change a dose on your own.

If you think your relative is being sent home too soon, Medicare patients can ask for a fast appeal. The hospital should give a notice called the Important Message from Medicare.

The first days at home

Do not wait for a problem to make a plan. A short plan for the first days can help.

1. Before arrival: Fill the prescriptions. Buy food for any special diet. Set up the equipment. Clear the path from the bed to the bathroom, and remove loose rugs and cords.
2. Arrival day: Check the medicine bottles against the discharge list. Decide who is home at each hour, day and night. Keep the discharge papers and the contact number in one place.
3. The next few days: Notice how your relative moves, eats, and sleeps. Write down questions and call the number on the discharge papers. If home health was ordered, confirm that the visits have started.
4. First follow-up visit: Bring the medicine list and your notes.

Recovery time is different for each person. Ask the care team what to expect and whether your relative is safe to be alone at any time of day. No single rule fits everyone.

Who will cover each task

Before discharge, go through this list. Decide who will do each task, and write the name next to it.

• Wound care, shots, and therapy: A nurse or therapist. Ask the care team who will do this and when.
• Bathing, dressing, toileting, walking, and transfers: Family or an aide.
• Meals and light housekeeping: Family or an aide.
• Medicine questions: The doctor, nurse, or pharmacist. A Cottage aide can give reminders. We do not manage or change medicines.
• Rides to appointments: Usually family. Ask any agency whether trips can be part of the plan.
• Insurance calls and forms: Family, with help from the discharge planner or a social worker.
• Nights and weekends: Decide this before discharge. See the next section.

If no one can stay

Tell the discharge planner before discharge if no one can be home. Say which hours are not covered. The team can use this when it decides where your relative goes next.

Know the limits of booked visits. A nurse who visits twice a week is not there on the other days. Medicare home health is part time, and Medicare does not pay for 24-hour care at home.

Ask about these options: a schedule shared by family and friends, a private pay aide, Medicaid help if your relative qualifies, or care in a facility if the care team says it is needed. The team decides what is safe for your relative. If an aide will be part of the plan, ask the agency which hours it can cover, including nights and weekends.

Costs and coverage

Medicare

Medicare may pay for part-time skilled home health care. Your relative must need skilled care, such as nursing or therapy, and must be homebound. A doctor or other provider must see your relative and order the care. A Medicare-certified home health agency must provide it.

Medicare can pay for an aide’s help with bathing or walking only while your relative also gets skilled care. It does not pay for personal care when that is the only care needed. It does not pay for 24-hour care at home. If your relative has a Medicare Advantage plan, check the plan’s rules.

The three-day rule

Medicare pays for a skilled nursing facility stay only after a hospital stay of at least three days in a row as an inpatient. The count starts the day your relative is admitted as an inpatient. It does not include the day they leave. Time in the emergency room or under observation does not count, even overnight.

Some Accountable Care Organizations and Medicare Advantage plans can waive the rule. Ask the hospital and the plan. This rule is about facility stays. It is not a rule for all home care.

New York Medicaid

Medicaid can pay for personal care at home for people who qualify. A Medicaid card alone is not enough. The usual steps are:

1. Your relative has active Medicaid.
2. A state assessor, the New York Independent Assessor Program, does the first assessment. Your relative or a representative can call 855-222-8350 to ask for it.
3. If your relative is eligible, a Medicaid plan or the local social services office uses the results to build a plan of care and approve services.
4. An agency that works with that plan staffs the approved hours.

Since September 1, 2025, new adult applicants must meet minimum needs rules. In general, that means needing hands-on help with more than two daily tasks, such as bathing or dressing. A person with a dementia or Alzheimer’s diagnosis may qualify by needing supervision with more than one daily task.

Short-term help after a hospital stay may not meet these rules. The state decides, not the hospital or Cottage. If the need is urgent, the state says to contact your local social services office or your Medicaid plan. They can help schedule the assessment.

Private pay

Private pay means your family pays the agency directly. It does not wait for an insurance decision. Before you choose any agency, ask these questions:

• What is the hourly rate?
• Is there a minimum number of hours per visit or per day?
• Is there a fee for the assessment?
• How are nights, weekends, and holidays billed?
• What happens if we change or cancel the schedule?
• Who fills in if the aide is sick?

Cottage Home Care offers private pay home care in New York. Call us and we can explain our rates and any minimum hours.

What Cottage Home Care can do

Cottage Home Care provides non-medical personal care at home through home health aides and personal care aides. Based on the care plan, an aide can help with bathing, dressing, grooming, toileting, walking and moving safely, medicine reminders, meal preparation, and light housekeeping.

We do not provide nursing, therapy, or medical advice. If your relative needs wound care, shots, or therapy, the doctor and the discharge team arrange that with a health care provider.

We serve Brooklyn, Queens, Manhattan, the Bronx, Staten Island, Nassau County, and Suffolk County. Our offices are in Freeport and Queens. Tell us your ZIP code and we can confirm whether we can staff your area.

Start dates depend on the payment route, any assessments, caregiver availability, and your schedule. We cannot promise a date. We can tell you what the next step is when you call.

Cottage private pay home care in New York Contact Cottage Home Care in New York

What to have ready when you call

• The ZIP code where care will happen.
• The discharge date, or the expected date.
• The tasks your relative needs help with, and the hours of the day.
• Mobility and equipment, such as a walker, wheelchair, hospital bed, or stairs at home.
• How you plan to pay: private pay, a Medicaid plan, or other coverage. If your relative has Medicaid, have the Medicaid ID number and the plan name.
• The name and phone number of a care team contact, such as the discharge planner.
• Your questions about nights and weekends.

Common questions

What is after hospital care called?+

People use several names, including post-hospital care, transitional care, and post-acute care. The names do not always mean the same services. Ask the hospital what is included, who provides it, and who pays.

What if no one can take care of my relative after discharge?+

Tell the discharge planner before discharge and name the hours that are not covered. Ask about a family schedule, a private pay aide, Medicaid help if your relative qualifies, or a facility if the care team says it is needed. Booked nurse visits do not replace someone being there all day.

Does Medicare pay for care after a hospital stay?+

It can pay for part-time skilled home health care ordered by a doctor, and for a limited skilled nursing facility stay after a qualifying hospital stay. It does not pay for personal care when that is the only care needed, and it does not pay for 24-hour care at home.

What is the three-day rule?+

It is a Medicare rule for skilled nursing facility stays. Your relative must first have at least three days in a row as an inpatient. Observation time and emergency room time do not count. Some plans and programs can waive the rule, so ask.

How long does it take to recover after a hospital stay?+

It depends on the person, the illness or surgery, and the support at home. Ask the care team what to expect for your relative and when to call them.

Will Medicaid pay for an aide after a hospital stay?+

It may, if your relative qualifies. In New York, the person needs active Medicaid and a state assessment, and a plan must approve the hours. Short-term help may not meet the rules. The state makes the decision.

Official pages for more detail

Medicare: home health services Medicare: skilled nursing facility care Medicare: your discharge planning checklist (PDF) MedlinePlus: leaving the hospital and your discharge plan New York State Department of Health: minimum needs rules for personal care New York State Health Profiles: look up a home care agency

If it helps to talk it through, call us or send a message. Tell us your ZIP code, the discharge date, the tasks you need, and how you plan to pay. There is no pressure to decide on the first call.

Call (516) 367-2266

Our office hours are Monday to Saturday, 8:30 a.m. to 5 p.m. Eastern. We are closed on Sundays. You can also write to info@cottagehomecare.com.