Elderly Parent Hospitalized? What to Do in the First 48 Hours

When an elderly parent is hospitalized, spend the first 48 hours on a short list: get your name and phone number into their chart, learn who the hospitalist and case manager are, and ask every day whether your parent is an inpatient or "under observation," because Medicare treats the two very differently. Then compare the hospital's medication list with the one you know is right, watch for sudden confusion, and pick one family member to do the talking. Somebody also has to feed the cat.

This guide picks up after the ambulance. Still in the ER? Start with what to bring to the ER for an elderly parent.

The first 48 hours at a glance

The first few hours: get your name in the chart

Find your parent's nurse first. Say who you are, give your cell number, and ask that it be written in the chart. Next Step in Care, a family caregiver program of the United Hospital Fund, recommends exactly this in What Is a Hospitalist?: give your number to everyone on the team and have it in the chart, so they can share information with you as the person responsible for your parent's care, unless your parent objects.

That "unless" is the federal privacy rule at work. The Family Caregiver Alliance's hospital discharge planning guide quotes HHS: if your parent is present and able to make decisions, a provider may talk with you if your parent agrees or doesn't object, and may share only what you need to know about their care or payment for it. The simplest move is to have your parent tell the nurse, "This is my daughter. You can tell her anything." If you hold their health care proxy, ask that a copy go into this admission's record, even if the ER saw it. A signed HIPAA authorization for a parent helps too.

Then make two calls the hospital may not make for you:

• Their primary care doctor. Next Step in Care notes that many hospitals don't tell community doctors when a patient is admitted. Give the office the hospital, the unit, and the hospitalist's name once you have it.
• Any specialist who manages something big, like a cardiologist or oncologist. Ask the hospitalist to check with that doctor about medications and recent tests.

Who's who on the hospital floor

People will walk in, introduce themselves fast and leave. Here's what the badges usually mean, drawing on Next Step in Care's hospital admission guide and the American Nurses Association's description of the charge nurse role.

Parents often ask where their own doctor is. According to Next Step in Care, the regular doctor probably won't come, hospitalists rotate in shifts so you may meet two or more in a week, and most don't provide care after discharge. Ask the hospitalist how to reach them, the best time to call, and when their shift changes.

Ask "inpatient or observation?" every day

Most families don't know to ask this, and money rides on it.

Medicare.gov's page on inpatient or outpatient hospital status lays it out. Your parent is an inpatient starting when they're formally admitted with a doctor's order. They're an outpatient if they're getting emergency or observation services and no doctor has written an order to admit them, even if they spend the night in a regular hospital bed. Observation is outpatient care while the doctor decides whether to admit or discharge. An inpatient admission is generally appropriate when the doctor expects your parent to need care spanning two or more midnights, but the doctor still has to order it.

Why it matters, under Original Medicare:

• The bill works differently. Medicare's Medicare Hospital Benefits fact sheet says Part A covers inpatient hospital services, and your parent generally pays one deductible for all of them for the first 60 days. Observation is outpatient care under Part B, where they generally pay a copayment for each hospital service. Doctor services fall under Part B either way, usually 20% of the approved amount after the Part B deductible.
• Their everyday pills may not be covered. The same fact sheet says Part B usually doesn't pay for "self-administered drugs" in hospital outpatient settings, meaning medicines they'd normally take on their own, like a daily blood pressure pill. Most hospital pharmacies aren't in Part D, so your parent may have to pay and submit a claim to their drug plan for a refund.
• Rehab coverage can depend on it. Medicare.gov's skilled nursing facility care page says Medicare covers a skilled nursing facility stay only after a medically necessary inpatient stay of at least 3 days in a row, counting the admission day but not the discharge day. Time under observation or in the ER before admission doesn't count, even overnight.

There are exceptions: your parent may not need the 3 days if their doctor participates in an Accountable Care Organization approved for a "Skilled Nursing Facility 3-Day Rule Waiver," and Medicare Advantage plans may also waive it. With a Medicare Advantage plan, costs and rules can differ, so call the plan.

The two notices to watch for

The MOON. If your parent gets observation services for more than 24 hours, the hospital must give them the Medicare Outpatient Observation Notice. According to the CMS fact sheet on the MOON, it has to arrive no later than 36 hours after observation starts (or at release, if sooner), someone has to explain it out loud, and your parent or the person acting for them is asked to sign that they received it. It explains why they're an outpatient and what that means for costs and later skilled nursing coverage.

The Important Message from Medicare. If your parent is an inpatient, Medicare's fast appeals page says they should get "An Important Message from Medicare about Your Rights" within 2 days of admission. It explains their discharge rights and how to ask for a fast appeal if they're being discharged too soon. If you don't see it, ask for it. Keep both notices with your notes.

One more situation: if your parent was admitted as an inpatient and the hospital later changes them to "outpatient getting observation services," Medicare.gov says the doctor must agree, the hospital must tell your parent in writing before discharge, and your parent can ask for a fast appeal while still in the hospital.

You can't argue your parent into inpatient status; that's a medical decision. What you can do is know the status early, before anyone starts talking about rehab.

Watch for delirium, and help head it off

Delirium is a sudden state of confusion. Hebrew SeniorLife, whose research institute is home to the Hospital Elder Life Program (HELP) that Dr. Sharon Inouye started in 1995, calls it one of the most common complications in hospitalized patients over 65. It can look like trouble following what's happening, saying things that don't make sense, seeing things that aren't there, or fearing that people are trying to harm them. HELP's approach targets mobility, nutrition and fluids, orientation and activity, sleep, vision and hearing, and families can help with most of those.

Its tips, and those on the HELP family page at the University of Rochester's Highland Hospital, add up to a few habits:

• Glasses and hearing aids on. Not in the drawer. If the hearing aids died, bring the charger.
• Up and moving, if staff say it's safe. Hebrew SeniorLife notes that many people assume patients should rest in bed, but bed rest can prolong recovery and lead to delirium. Ask the nurse or PT whether your parent can sit in a chair or walk the hall with help.
• Food and water. Notice whether the meal tray comes back full and whether the water cup is in reach. Ask before bringing food from home; their diet may be restricted.
• Real nights. Dim, quiet rest times. The TV doesn't need to run all day.
• Familiar faces and talk. Visits from people they know, conversation about the news or the view out the window, reading aloud.
• A few things from home. A family photo, their own blanket.

Most of all, tell the nurse when something seems off. The Health in Aging Foundation's delirium tip sheet reminds families that they know the person better than the hospital staff do and are often first to see the change. It lists common reversible causes to raise with the team, including new or changed medications, untreated pain, constipation, infections and dehydration. Hebrew SeniorLife adds that providers don't always recognize delirium, so they should hear what family has noticed. "Dad did his own taxes in April" is useful information when Dad is now asking what year it is.

Next Step in Care says confused patients are often less confused when family stays with them, and Health in Aging notes many hospitals allow a family member overnight. Ask the unit.

Go over the medication list together

On day one, ask the hospitalist or nurse to go over your parent's home medications with you. This is medication reconciliation: comparing what they take at home with what's ordered here. Next Step in Care says to ask to be included, and points out that you may know more about the medications than your parent does.

Bring the up-to-date list, or a photo of it. Our guide to a medication list for an elderly parent shows the columns that matter. Check for:

• Anything on the home list that isn't ordered here, and whether that's on purpose
• Anything new, and what it's for
• Over-the-counter drugs, vitamins and supplements, which Next Step in Care specifically says to mention
• Allergies, with what actually happened (rash, trouble breathing)

The hospital provides your parent's medications, so Next Step in Care says to leave the pill bottles home unless the doctor asks. Write down any changes now; the list that leaves the hospital may not match the one that came in.

One point person, one update

By hour twelve you'll have nine missed calls from relatives who want the same update, and the nurses are getting those calls too. Pick one person to talk to the hospital and one channel for everyone else. If that's you and you live hours away, our long-distance caregiving checklist covers what to set up from afar.

The point person is the one whose number is in the chart, ideally the health care agent or whoever will help most after discharge. They keep a notebook (or a phone note) of each conversation, with date, time, name and role, and send one update a day to the family group at about the same time, so nobody has to ask. Something like:

One more habit from Next Step in Care: at shift change, ask the departing nurse what needs to happen next shift, including medications and tests, and make sure the incoming nurse knows it too.

Discharge planning starts on day one

It feels backward to talk about leaving on day one. But Next Step in Care's hospitalist guide notes that patients are often discharged when they're stable but not fully recovered, sometimes with little notice. AARP caregiving expert Amy Goyer, writing about transitions from hospital to rehab to home, says not to wait until discharge is imminent: ask to speak with a discharge planner or social worker right away.

In the first two days, you're only starting the conversation:

• Ask the hospitalist roughly when discharge might be, since they're the one who signs off on it.
• Tell the case manager where your parent lives, who lives with them, the stairs, and who can realistically help. The Family Caregiver Alliance stresses telling discharge staff about your own limits, whether that's a job, kids, distance or your back.
• Ask whether rehab, home health or help at home is likely, so you aren't picking from a list in the hallway.

The Family Caregiver Alliance also describes the CARE Act, now law in most states, which requires hospitals to record the family caregiver's name in the medical record, tell the caregiver when the patient is being discharged, and teach the caregiver any medical tasks they'll need to do at home. If your state has it, make sure your name is the one on file.

The full discharge checklist comes later in the stay. For now, the goal is that nobody is surprised.

Meanwhile, at their house

An empty house can get into trouble fast. Within the first 48 hours, someone should:

• Feed and walk the pets, and line up who does it for the next week.
• Lock up and check the stove, faucets and space heaters. After an ambulance ride, things may still be on.
• Bring in the mail, and look for bills with due dates coming up.
• Check which bills are on autopay. Rent or mortgage, utilities, insurance premiums and credit cards cause the most trouble if missed.
• Toss anything in the fridge that will spoil.
• Cancel or move appointments for the next couple of weeks: hairdresser, dentist, Meals on Wheels, the cleaner, the home aide.
• Tell the people who will notice they're gone: a close friend, their faith community, the neighbor who sees them walk the dog.
• Find the spare key and give it to whoever is covering the house.

This is when families learn whether anyone knows which bank Dad uses. If your parent has an emergency binder, this list is mostly a matter of opening it to the right tab.

Questions to ask in the first 48 hours

Write these in the notebook with room for answers.

• What's the working diagnosis, and what tests are you waiting on?
• Who is the doctor in charge, and how do I reach them?
• Can they get up and walk, and how often?
• Is the confusion I'm seeing new to you, or has it been there since admission?
• When is the best time each day to get an update?
• If they have a POLST or advance directive, is it in this admission's chart? (Our guide to the POLST form explains what that document does.)

Two more things Next Step in Care says you can ask for: an interpreter, including a sign language interpreter, and the hospital's ethics committee if you and the team disagree about a major treatment decision.

Take care of the person in the plastic chair

That's you. Next Step in Care's advice is plain: eat when you can, let others take over for a break, and rest. Go home and sleep if someone can cover. The notebook will tell you what you missed.

Frequently asked questions

What is the difference between observation status and inpatient status for Medicare?

An inpatient has been formally admitted with a doctor's order. A patient under observation is an outpatient, even after a night in a hospital bed. Observation is billed under Part B, which can mean more out-of-pocket costs, and observation days don't count toward the 3-day inpatient stay Original Medicare requires before covering skilled nursing facility care.

What does a hospital case manager do?

The case manager or social worker helps with insurance questions and plans what happens after the hospital: going home with or without home health, short-term rehab, or another facility. Introduce yourself in the first day or two, not the morning of discharge.

Should someone stay with an elderly parent in the hospital overnight?

If the hospital allows it and you can manage it, it can help, especially if your parent gets confused. If nobody can stay, short frequent visits and being there at mealtimes help too.

What can I do if I think my parent is being discharged too soon?

Tell the nurse or case manager right away. If your parent is a Medicare inpatient, the Important Message from Medicare explains how to request a fast appeal from an independent reviewer. Medicare.gov says to follow its directions no later than the day of the planned discharge; if you do, your parent can stay in the hospital while waiting for the decision.

Before the next phone call

Most of what makes the first 48 hours hard is hunting: for the medication list, the proxy, the insurance cards, the vet's name, which bills come out automatically. You can gather it yourself with this article and a free evening. Emergency Binder Now can also pull it together from about 25 minutes of guided questions, giving you a printable binder with a one-page Emergency Information Sheet up front and a list of anything still missing. Here's a sample binder to see what it covers.

This article is general information, not medical, legal or financial advice. Ask your parent's care team about their treatment, and their Medicare plan or a Medicare counselor about coverage.