From the hospital to assisted living: a discharge guide for Mesa families

Short answer: When the hospital says your parent can't safely go home, ask the case manager for the discharge timeline, whether a short rehab stay is recommended, and a copy of the medication list and physician's orders. Then call two or three assisted-living homes that can meet the care needs (dementia, transfers, insulin) and your payer (private pay or ALTCS). Many homes can assess at the hospital and move quickly.

The first 72 hours

1. Find the case manager or discharge planner. Ask for the expected discharge date and the care team's recommendation.
2. Ask whether rehab comes first. After surgery, a stroke or a serious fall, Medicare may cover a short skilled-nursing rehab stay that buys you time.
3. Get the paperwork: current medication list, diagnosis list, physician's orders, therapy notes, and a TB screening if one was done.
4. Be honest about care needs. Can Mom transfer on her own, or does she need a Hoyer lift? Is she exit-seeking? Is she on insulin? These decide which homes can take her.
5. Know your payer. Private pay, long-term care insurance, VA, or ALTCS (approved or pending). It narrows the list fast.
6. Call homes directly. A good home will tell you in one call whether they're a fit and can often assess your parent at the hospital or rehab.

You don't have to accept the first bed offered

Hospitals need beds, and the pressure is real. But you can ask for an extra day while you tour, or choose a short rehab stay to give yourself time. You can also use a placement agent (free to families; the home pays the fee) to shortlist options quickly.

Where ALTCS fits

If your parent will need ALTCS, apply as early as possible; approval can take up to 90 days. Many families private-pay at the assisted-living home while the application is pending, then switch. Read ALTCS assisted living in Mesa.

What Fountain can take from the hospital

We're a directed-care assisted living center, so we can admit residents with dementia (including wandering), Hoyer-lift transfers, insulin, catheter care and incontinence. We can't take hospice, behavioral-health needs, or anything requiring a nurse on site. Hospital case managers can find our full criteria on our referral page, or call (480) 299-3310.

Common questions