Leaving a New York hospital or rehab: how to get help at home

New York's rules are stronger than most families realize. The Department of Health's patient rights booklet says: "All patients (including Medicare patients) in New York State hospitals must receive a written discharge plan before they leave the hospital." The regulation adds that the plan is developed "together with the patient and the patient's family/representative," and the Patients' Bill of Rights lets you "identify a caregiver who will be included in your discharge planning." Name that person on day one.

Two kinds of notice follow:

• Medicare patients get "An Important Message from Medicare about Your Rights," which Medicare.gov says should arrive "within 2 days of your admission and prior to your discharge." It explains a fast appeal: follow the directions "no later than the day you're scheduled to be discharged," and "you can stay in the hospital while you wait" for the decision without paying for the stay beyond normal coinsurance. In New York, the review organization's number printed on CMS's contact page is 1-866-815-5440.
• Everyone else must get a written discharge notice "24 hours before they leave the hospital," and the State's required wording says: "You have the right to appeal the written discharge plan or notice." For Medicaid patients, the DOH booklet lists the review line at 1-800-648-4776; the request has to be made by the planned discharge date to avoid charges.

Rehab has its own version. Medicare.gov says a skilled nursing facility must give a "Notice of Medicare Non-Coverage" at least two days before covered services end, and the appeal must be filed "no later than noon the day before the termination date listed on the notice."

Use these rights to buy time, not to fight. A day or two often makes the difference between an aide in place and a gap.

NY Connects describes itself as "your trusted place to go for free, unbiased information and assistance" that can "link to long term services and supports, such as home care, transportation and meals," for people of any age, any disability, "regardless of diagnosis, age or payor source." Its number is 1-800-342-9871. Call from the hospital room. Say: "My parent is being discharged on [date]. They do / do not have Medicaid. They are [age]. Which program should we start, and who do we call first?" NY Connects cannot assess anyone or authorize hours, but it will sort the doors below in a few minutes.

Question 1: Is there a skilled need right now?

If the person needs a nurse, physical therapy, or wound care at home, the discharge planner can arrange Medicare home health. Medicare.gov says it covers "part-time or intermittent skilled nursing care," therapies, and "part-time or intermittent home health aide care (only if you're also getting skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy at the same time)." The person must be homebound, which Medicare defines as normally "unable to leave your home and leaving takes a lot of effort."

What it does not do, in Medicare's own list: "24-hour-a-day care at your home," "home meal delivery," "homemaker services," and "custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need." The combined cap is "up to 8 hours a day (combined), for a maximum of 28 hours a week," and it ends when the skilled need ends. When the discharge plan says "home care arranged," ask which kind. It is usually this one.

Question 2: Does the person have Medicaid, or could they?

Yes, active Medicaid. The door is the New York Independent Assessor Program (NYIA). Its FAQ says people 18 and older "who have Medicaid, or both Medicaid and Medicare, can be assessed," and that the two appointments can happen "at your home, a family member or friend's home or apartment, or at a facility where you are receiving services," in person or by video. That last phrase matters: ask NYIA whether the nurse's visit can happen before discharge. The number is 1-855-222-8350 (TTY 1-888-329-1541). If the person is in a Medicaid managed care plan, the FAQ says to contact the plan, which calls NYIA with you on the line. Our NYIA prep checklist covers both appointments.

Yes, and the need is urgent. New York has an "immediate need" process. The attestation form (DOH-5786) lists the conditions: "no informal caregivers available, able and willing," not already getting help from an agency, no equipment that would meet the need, and "no third party insurance or Medicare benefits available to pay for needed help." It goes, with a practitioner's form (DOH-5779), "to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA)." The form itself has a box for people "in a nursing home or a hospital setting" who "have a date set to return home." The State's directive sets the clock: a personal care decision "no more than 12 calendar days" after a complete request, and NYIA scheduling both appointments "within six (6) calendar days" of the district's referral. One trap: the directive says that if someone "is directed to the NYIA by a discharge planner," NYIA sends them back to file with the district. "Individuals may not bypass the LDSS." In the city, HRA's home care line is 718-557-1399.

No, but they might get it. Apply now, through HRA in the city or the county Department of Social Services elsewhere. Our post on where Medicaid home care starts covers the form and documents. The immediate need attestation can be filed with the Medicaid application, and the district must decide the Medicaid part "no later than 7 days" after a complete application.

Both Medicare and Medicaid, needing care for more than 120 days. The person will likely need a Managed Long Term Care plan. DOH's consumer guide says you must join one if you are 21 or older, have both, and are receiving community-based long-term services "for more than 120 continuous days based on an assessment." Enrollment runs through New York Medicaid Choice at 1-888-401-6582, after the NYIA assessment. No hospital, rehab, or agency can do that step; see MLTC enrollment steps.

Question 3: No Medicaid, 60 or older?

The door is EISEP, the State's non-Medicaid in-home program, through the county Office for the Aging or, in the city, NYC Aging (Aging Connect 212-244-6469). The State's page describes it as "coordinated, nonmedical services for older adults who aren't eligible for Medicaid," with a case manager, in-home help, respite, and small home fixes. Intake is a phone call and a home visit; hands-on services carry a sliding fee; many counties have waiting lists. Our EISEP explainer has the 2026 fee rules. Start the intake before discharge, because the wait is the constraint.

Question 4: Is the real problem the apartment, the food, or the ride?

If the person has Medicaid and the discharge is failing for reasons an aide cannot fix, ask about the Social Care Network. DOH's member page says networks screen Medicaid members for needs like living situation, food, and transportation, and that some managed care members with qualifying conditions can get "one-time or temporary services (up to 6 months)," such as "home-delivered meals" and "home safety modifications for those with a physical disability." One listed qualifying category is "Having frequent visits to the emergency room or hospital." DOH's eligibility summary also lists recuperative care after an acute hospital stay and housing help for people who left a hospital or nursing facility "within the past 90 days," both tied to a housing need. Screening starts at screening.shinny.org; our how-to-connect post walks through it. This is not home care, and it does not replace NYIA.

Only one thing usually starts the day of discharge: Medicare home health arranged by the hospital. Everything else runs on its own clock. Immediate need has a 12-day decision window. Regular NYIA cases wait for two appointments, a letter, and then a plan's own visit. EISEP waits for an intake, a home visit, and often a list. That is why the hospital's duty not to discharge until services are "secured or determined by the hospital to be reasonably available" is the lever. If the plan is "family will manage" and the family cannot, say so in writing to the discharge planner and ask for the plan to be revised.

One more door exists for people trying to leave a nursing home rather than a hospital: the Nursing Home Transition and Diversion waiver. At the time of writing, DOH's page says it has "reached the approved maximum number of participants" and is not taking new referrals. Ask NY Connects whether that has changed.

• Hearing "home care is set up" and not asking which kind. Medicare home health ends in weeks. Ask what happens after.
• Calling NYIA from the hospital for an urgent case. NYIA will send you to HRA or the county. File the immediate need forms there first.
• Attesting to immediate need while a Medicare home health episode is running. The form says no Medicare benefit may be available to pay for the help. Time it honestly.
• Signing the discharge plan without a caregiver named. The Bill of Rights lets you name one. Do it.
• Letting the Medicaid case lapse during the stay. A renewal missed in the hospital stops every Medicaid door.
• Skipping the fast appeal because it feels confrontational. It is a form, it is free, and it holds the bed while the plan gets fixed.

Can the hospital discharge my parent before home care is in place?

New York's regulation says no patient who requires continuing health care services under the discharge plan "may be discharged until such services are secured or determined by the hospital to be reasonably available." You also have a written right to appeal the discharge plan or notice. Ask the discharge planner to show you the plan and to put any changes in writing.

Does Medicare pay for an aide after the hospital?

Only part-time, and only alongside skilled care such as nursing or therapy. Medicare.gov says it does not pay for personal care with bathing, dressing, or using the bathroom "when this is the only care you need," and never for 24-hour care.

Can NYIA assess someone who is still in the hospital or rehab?

NYIA's FAQ says appointments can take place "at a facility where you are receiving services," in person or by video, as long as Medicaid is active. Ask when you schedule; this site cannot promise how a given case is handled.

What is "immediate need"?

A faster Medicaid personal care track for people with no one able and willing to help, no agency already helping, no equipment that would solve it, and no Medicare or other insurance available to pay. It is filed with HRA in the city or the county Department of Social Services elsewhere, not with NYIA, using forms DOH-5786 and DOH-5779.

My mother is 70, not on Medicaid, and needs help. Who do we call?

NY Connects at 1-800-342-9871, or Aging Connect at 212-244-6469 in New York City, and ask for in-home services for someone 60 or older who is not on Medicaid. That is the EISEP door.