Last verified: October 2026
What should you do when a Baltimore hospital says a parent is being discharged in two or three days?
Ask the case manager for the discharge plan in writing, confirm whether the stay was inpatient or observation, ask which facilities have already accepted the referral, and check each one's license or CMS record before agreeing.
- Inpatient or observation? Only inpatient days count toward the three-day stay Medicare requires before covering skilled nursing care.
- Which places said yes? Case managers often send referrals to many facilities; the accept list is the real list.
- Check the record. For nursing homes, open the CMS rating and latest survey; for assisted living, confirm the OHCQ license and level.
- Ask about the date. A discharge date can often move a day if no safe plan exists yet; you can appeal a Medicare discharge you disagree with.
Should the next step be rehab or assisted living?
If daily skilled therapy or nursing is needed, a skilled nursing facility stay comes first; if the main need is supervision and help with daily activities, a Level 3 assisted living program may be the right discharge destination.
Maryland assisted living cannot admit someone who needs more than intermittent nursing, treatment of stage 3 or 4 pressure ulcers, or a ventilator, unless a licensed hospice is involved.
Which hospitals discharge most Baltimore patients to rehab?
The large academic and community hospitals -- Johns Hopkins, the University of Maryland Medical Center, Sinai, MedStar Franklin Square, GBMC, UM St. Joseph and Baltimore Washington Medical Center -- each work with dozens of nursing homes, so the facility list you receive is long.
Use the nursing home directory to sort the list by CMS rating or latest-survey deficiencies.
Is a discharge planner the same as an advisor?
No.
| Hospital case manager | Senior care advisor |
|---|---|
| Works for the hospital; focuses on a safe, timely discharge | Works with the family on the longer-term fit |
| Sends referrals to many facilities | Narrows to a few that fit care and budget |
What paperwork does an assisted living program need for a hospital discharge?
A Maryland assisted living program needs a pre-admission assessment, a physician's health care evaluation and medication orders before admission, and it will want the hospital discharge summary to set the resident's level of care and service plan.
Ask the hospital case manager to send the discharge summary and medication list directly to the program the day before discharge. Confirm who will deliver the first week of medications and whether home health or hospice will follow the resident at the program. If the program's licensed level is below what the assessment shows, it will need an OHCQ waiver, which can take up to seven days -- another reason to check the level first.
