About us: NoVA Home Care Guide is a free information and referral service. We are not a home care provider, a hospital, or a medical practice, and we are not affiliated with any hospital named on this page. This page is general information, not medical or legal advice.
The short answer
- Ask for the discharge planner or case manager today and tell them plainly that no one can provide care at home yet.
- Name a family caregiver. In Virginia, the hospital must let your parent name one, share the plan with them, and show them the care tasks before discharge.
- If your parent isn’t ready, ask for a fast Medicare appeal no later than the day of discharge (Original Medicare).
- Find out what Medicare home health will cover (short nursing and therapy visits) and what it won’t (daily or 24-hour help).
- Line up home care before the discharge date for meals, bathing, medication reminders and overnight help.
Before your parent leaves the hospital: questions to ask
Ask for a meeting with the discharge planner (sometimes called a case manager or social worker). Bring a notebook, or ask if you can record. These are the questions families most often wish they had asked.
- What is the planned discharge date and time? Can it move if help isn’t ready?
- Is my parent admitted as an inpatient, or under observation? It changes what Medicare covers afterwards, including rehab in a nursing facility.
- What can they do on their own right now: walk, use the toilet, shower, climb stairs, get in and out of bed?
- Will they need help at night? How many hours a day should someone be with them?
- Is a doctor ordering home health (nursing or therapy visits)? Which agency, and when is the first visit?
- What medicines change, start or stop? Can we get a printed list and have the pharmacist explain it?
- What equipment is needed: walker, shower chair, raised toilet seat, hospital bed? Who orders it?
- What warning signs mean we should call the doctor, and what means call 911?
- When are the follow-up appointments, and who arranges transportation?
- Would short-term rehab in a skilled nursing facility be safer first? Would Medicare cover it in this case?
Your rights as the family caregiver in Virginia
Virginia law (Code of Virginia § 32.1-137.03) requires hospitals to give each inpatient the chance to name a caregiver. Before discharge, the hospital must notify that caregiver, give them a copy of the discharge plan and instructions, consult them about whether they can provide the care, and let them practice the follow-up tasks and ask questions, in their own language. If this hasn’t happened, ask for it.
Not ready to go home? Your right to a fast Medicare appeal
If your parent has Original Medicare, the hospital gives them a notice called the “Important Message from Medicare.” It explains how to appeal a discharge you think is too soon. Families often don’t realize this right exists, or that the clock runs out on discharge day.
- Find the Important Message from Medicare notice in the discharge papers.
- Call the Medicare reviewer (BFCC-QIO) using the number printed on that notice.
- Ask no later than the scheduled discharge day.
- An independent doctor reviews the record. Decisions usually come within days.
If you ask in time, your parent can stay in the hospital while the case is reviewed and won’t pay for those extra days, apart from normal coinsurance or deductibles.
Medicare Advantage plans have their own appeal rules. Call the number on the plan card the same day you learn of the discharge.
Home health vs home care: what’s the difference?
Families hear both terms in the hospital, and they are not the same thing. Most parents coming home need some of each.
| Home health | Home care | |
|---|---|---|
| What it is | Skilled medical care: nursing, physical, occupational or speech therapy | Non-medical daily help: meals, bathing, dressing, toileting, light housekeeping, companionship, medication reminders |
| Who orders it | A doctor, with a care plan | The family. No doctor’s order needed |
| How much time | Short visits, part-time or intermittent | A few hours a day, up to overnight, live-in or 24-hour schedules |
| Who usually pays | Often Medicare, if the person is homebound and needs skilled care | Usually private pay or long-term care insurance; sometimes VA or Medicaid programs |
| Good to know | The hospital or doctor usually picks or suggests the agency, but you can ask for a different one | You choose the agency, the schedule and the caregiver match |
What Medicare does not cover at home: 24-hour care, meal delivery, homemaker services like shopping and cleaning, and personal care like bathing or dressing when that is the only care needed. That gap is why most families arrange private home care for the first weeks after discharge.
How much help will your parent need?
Home care agencies usually offer three kinds of schedules. Pick the one that matches what your parent can safely do alone, and adjust after the first week.
A few hours a day
Help with a shower, meals, light housekeeping and medication reminders.
Best for: a parent who is safe alone most of the day.
Overnight
Someone in the home at night. Ask whether the caregiver stays awake or may sleep.
Best for: a parent who gets up at night or is at risk of falling.
Live-in or 24-hour
Live-in: one caregiver who stays, with sleep and breaks. 24-hour: shifts, so someone is always awake.
Best for: a parent who can’t be left alone.
About medicines: what a caregiver may do with medicines depends on the agency’s license and Virginia rules. Many non-medical caregivers can give reminders but cannot administer medication. Ask each agency exactly what their caregivers are allowed to do.
Getting the home ready before discharge day
- Clear walkways. Remove loose rugs and cords.
- Set up a bedroom on the main floor if stairs are hard.
- Put a night light between the bed and the bathroom.
- Add a shower chair, grab bars and a raised toilet seat if recommended.
- Fill new prescriptions before or on the way home, and set up a pill organizer.
- Stock easy meals and drinks for the first week.
- Post the doctor, pharmacy and home health phone numbers on the fridge.
The first 72 hours and the first two weeks
- Day 1: coming homeSomeone should be there for the trip home and the first night. Go over the medicine list together.
- First 72 hoursWatch for the warning signs the hospital gave you. Make sure the home health agency has called to schedule the first visit.
- First weekKeep the follow-up appointment with the primary doctor. Bring the discharge papers and the medicine list.
- Week two: check the planIs your parent eating, sleeping and moving safely? Adjust the care hours up or down.
Choosing a home care agency: 8 questions to ask
Whether you find an agency through us or on your own, ask every agency the same questions so you can compare them fairly.
- License: Are you licensed in Virginia? Can you share the license number?
- Screening: How are caregivers screened, background-checked and trained?
- Employees: Are caregivers your employees, and are they insured and bonded?
- Supervision: Who supervises caregivers, and how often do they check in?
- Medicines: What exactly may your caregivers do with medicines?
- Minimums: What is the minimum number of hours per visit or per week?
- Backup: What happens if our caregiver is sick or doesn’t show up?
- Contract: How much notice do we need to give to change or stop care?
Ways families pay for home care
Private pay
Most families pay by the hour from savings or income, at least for the first weeks.
Long-term care insurance
If your parent has a policy, call the insurer now. Many policies have a waiting period before benefits start.
VA benefits
Some veterans and surviving spouses may qualify for Aid and Attendance payments that help pay for care.
Virginia Medicaid
People who qualify may get personal care through a Virginia Medicaid program. Your local Area Agency on Aging can help you apply.
Chose hospice at home? You may still need a caregiver
Hospice care is usually provided at home. The hospice team (nurse, aide, social worker, chaplain) visits on a schedule, but they generally don’t stay all day.
Many families add private caregivers for the hours in between, especially at night, so family members can rest. Ask the hospice team how many aide hours they will provide, then plan the rest.
Free help in Northern Virginia
Every county and city has an Area Agency on Aging with free information, care coordination and caregiver support. Call the one where your parent lives.
| Where your parent lives | Agency | Phone |
|---|---|---|
| Fairfax County, Fairfax City, Falls Church | Fairfax Area Agency on Aging | 703-324-7948 |
| Loudoun County | Loudoun County Area Agency on Aging | 703-777-0257 |
| Prince William County, Manassas | Prince William Area Agency on Aging | 703-792-6374 |
| Arlington County | Arlington Agency on Aging | 703-228-1700 |
| City of Alexandria | Alexandria Division of Aging & Adult Services | 703-746-5999 |
Phone numbers from the Virginia Division for Aging Services directory, checked November 4, 2026.
The steps on this page are the same whether your parent is at Inova Fairfax, Inova Alexandria, Inova Loudoun, Virginia Hospital Center, Reston Hospital Center, Sentara Northern Virginia, or another hospital in the area. We are not affiliated with any of them.
Need help at home?
Tell us a little about the situation and we'll connect you with one home care agency that serves your area.
- Free, with no obligation to hire
- One agency calls you, usually the same or next business day
- Your details are never sold to a list of companies
Frequently asked questions
Can the hospital send my parent home if no one can care for them?
Hospitals must plan a safe discharge. In Virginia, the hospital must give the patient a chance to name a caregiver, share the discharge plan with that caregiver, and let them practice the care tasks before discharge. If you believe your parent is not ready and they have Original Medicare, you can ask for a fast appeal no later than the day of discharge.
Does Medicare pay for a caregiver at home after a hospital stay?
Medicare covers part-time or intermittent home health care, such as nursing visits and therapy, when a doctor orders it and the person is homebound. It does not cover 24-hour care at home, meal delivery, homemaker services, or personal care like bathing when that is the only care needed. Most families pay privately for that kind of daily help.
What is the difference between home health and home care?
Home health is skilled medical care ordered by a doctor, such as nursing or physical therapy, delivered in short visits and often covered by Medicare. Home care is non-medical daily help, such as meals, bathing, dressing, light housekeeping, companionship and medication reminders, usually paid privately or by long-term care insurance.
How fast can home care start after discharge?
Many home care agencies can start within a day or two once an assessment is done, but availability varies, especially for overnight or 24-hour schedules. Start calling before the discharge date, not after.
What should I ask a home care agency before hiring?
Ask whether the agency is licensed in Virginia, how caregivers are screened and trained, whether caregivers are employees and insured, who supervises them, what they may do with medicines, the minimum hours per visit, and how backup caregivers are arranged if someone is sick.
My parent chose hospice at home. Do we still need a caregiver?
Often, yes. Hospice care is usually provided at home, with the hospice team visiting on a schedule. Hospice staff generally do not stay all day, so many families add private caregivers for the hours in between. Ask the hospice team how many aide hours they will provide.
Where can we get free help in Northern Virginia?
Each county and city has an Area Agency on Aging that offers free information, care coordination and caregiver support: Fairfax Area Agency on Aging (703-324-7948), Loudoun County Area Agency on Aging (703-777-0257), Prince William Area Agency on Aging (703-792-6374), Arlington Agency on Aging (703-228-1700), and Alexandria Division of Aging and Adult Services (703-746-5999).