Hospital discharge with nowhere safe to recover: medical respite and housing next steps for Medicare patients

Introduction

Leaving the hospital is supposed to be a step toward recovery. But if you are discharged from the hospital with no housing or nowhere safe to rest, it can feel scary and unsafe.

If you are in this situation, you still have options. You can ask for a stronger discharge plan, request a referral to a medical respite program (also called recuperative care), and get help coordinating medications, follow-up care, and housing after hospitalization.

Key takeaways

• Medical respite (recuperative care) is short-term residential care that supports healing for people experiencing homelessness who do not need hospital-level care.
• If you think you are being discharged too soon, Medicare has a fast appeal process, and you should receive a notice about your rights.
• A hospital must have a discharge planning process that includes evaluating your post-hospital needs and helping coordinate a safe transition.
• A trained advocate can help by coordinating discharge planning, referrals, medication access, follow-up care, transportation, and housing navigation.

If you are being discharged and you do not have a safe place to recover

A safe discharge plan is not just about the date you leave. It is about whether you can safely manage your medications, follow-up care, wound care, mobility needs, and basic daily living after you leave.

When you have nowhere safe to recover, the risks are higher. Without a stable place to rest, it can be harder to take medications correctly, keep wounds clean, store supplies, attend follow-up appointments, or notice early warning signs that you need medical help.

If you are still in the hospital, speak up early. Tell your care team clearly: “I do not have a safe place to recover after discharge.” Ask for the hospital case manager or social worker, and ask for a discharge planning evaluation.

What Medicare requires in discharge planning and what you can ask for

Hospitals that participate in Medicare are expected to have a discharge planning process that focuses on your goals and includes you and your caregiver or support person when possible. Discharge planning should include evaluating what services you may need after hospitalization and whether those services are available and accessible to you.

If you are worried about a safe discharge, ask for these items in plain language:

• A written discharge plan that matches your medical needs and your real living situation
• A complete medication list, including what changed and why
• Prescriptions that are filled or a clear plan for how you will get them
• Follow-up appointments scheduled, or written instructions on how to schedule them
• Transportation planning for follow-up visits
• Needed medical equipment (for example, walker, oxygen, wound supplies) and instructions on use
• Clear “return to care” warning signs, including when to call 911 versus your clinic

You can also ask the team to document your housing situation in the chart, because it affects safety and follow-up planning.

If you think you are being discharged too soon

If you have Medicare and believe the hospital is discharging you too soon, you can request a fast appeal. In many cases, you should receive a notice called “An Important Message from Medicare about Your Rights” (often called the IM). The Medicare fast appeal process uses a Quality Improvement Organization (QIO) to review whether you are ready to leave.

If you want to appeal, act quickly. Ask your nurse, case manager, or social worker for the notice and instructions, and ask them to help you contact the QIO listed on your paperwork.

What medical respite is and who qualifies

What is a medical respite program?

Medical respite care (also called recuperative care) provides a short-term place to stay for people experiencing homelessness who are too ill or frail to recover on the streets or in a shelter, but who do not require hospital-level care. It is designed to support healing while connecting you to medical care and other supportive services.

Medical respite is not the same thing as “respite” for caregivers. It is post-acute recovery support for the patient.

Who usually qualifies?

Each medical respite program has its own criteria, but many programs look for all of the following:

• You are experiencing homelessness or do not have a stable, safe place to recover
• You are medically stable enough to leave the hospital, but still need recovery support
• You can meet the program’s safety requirements, which may include basic mobility or willingness to accept assistance
• Your needs fit what the program can safely provide (some programs support higher clinical needs than others)

National standards and model descriptions emphasize that medical respite programs provide a safe place to heal plus access to clinical care and supportive services, but the intensity of services can vary by program model.

What services medical respite often provides

Many programs aim to provide a stable place to rest plus services that make recovery possible, such as basic clinical monitoring, help coordinating appointments, and enabling services like transportation and care coordination. Program guidance commonly describes essentials like consistent access to a bed, meals, help with care transitions, and support connecting to ongoing care.

How to get referred from a hospital

Hospitals are a major referral source for medical respite. If you think medical respite is the safest next step, ask directly for a referral.

Here is a script you can use:

• “I do not have safe housing after discharge. Can you refer me to medical respite or recuperative care?”
• “Can you document my housing situation and request a discharge planning evaluation today?”
• “If medical respite is not available, what is the safest alternative plan?”

Steps that usually help:

• Ask to speak with the hospital social worker or case manager as soon as possible
• Ask the team to send the referral early, since beds can be limited
• Ask what medical information the respite program needs (for example: diagnosis, mobility status, wounds, medication list, follow-up needs)
• Ask what the backup plan is if no respite bed is available that day

Medical respite programs exist in many communities, but availability and admission timing vary.

What to bring to intake

Intake requirements vary by program, so ask the hospital team what the specific site expects. In general, it helps to bring items that allow safe follow-through on your medical plan.

Consider bringing:

• Photo ID (if you have it) and any insurance cards
• Hospital discharge papers and instructions
• A current medication list and, if possible, the actual medications you were given or filled
• Pharmacy contact information
• A list of allergies and major medical conditions
• Follow-up appointment details (dates, locations, phone numbers)
• Mobility aids and medical equipment you already use (walker, cane, braces, hearing aids, glasses)
• A phone and charger if you have one
• A small amount of clothing and basic toiletries, if allowed
• Any documents that matter for your care, such as advance directives or a healthcare proxy (if you have them)

If you do not have these items, do not assume you are out of options. Tell the intake staff what you are missing. Many programs expect that people may arrive with limited belongings.

What an advocate does during discharge and after

When you are managing a hospital discharge with nowhere safe to recover, the work is more than paperwork. A strong advocate can help protect your safety and reduce the chance of a preventable return to the hospital.

An advocate can help you:

• Coordinate communication with the hospital case manager, social worker, and clinical team
• Track referrals and paperwork for medical respite (recuperative care) and other step-down options
• Confirm your medication list, identify gaps, and help you access prescriptions
• Arrange follow-up care and specialist appointments
• Coordinate transportation to follow-up visits and pharmacy pick-ups
• Help with housing after hospitalization, including connecting to local housing and shelter resources
• Support applications for benefits or financial assistance that may make care and housing more accessible

If you want to understand how care advocates support coordination step by step, see:

• https://understoodcare.com/healthcare-info/how-our-care-team-assists-you
• https://understoodcare.com/care-types/care-coordination
• https://understoodcare.com/care-types/appointments
• https://understoodcare.com/care-types/transportation-help
• https://understoodcare.com/care-types/application-help
• https://understoodcare.com/healthcare-info/financial-help

If medical respite is not available: other safe next steps

Sometimes a medical respite bed is not available right away. If that happens, your goal is still the same: do not accept a plan that makes your recovery medically unsafe.

Ask about Medicare-covered post-acute care when medically necessary

Depending on your condition, you may qualify for a skilled nursing facility (SNF) stay or other post-acute services if you meet Medicare coverage rules. Medicare explains SNF coverage limits and requirements, including that coverage is tied to medical necessity and benefit periods.

For Original Medicare, SNF coverage often relates to a qualifying inpatient hospital stay, and “observation status” does not count the same way as inpatient days. CMS guidance explains the common “3-day rule” details and why the inpatient versus observation distinction matters.

If you are unsure about your hospital status, ask: “Am I inpatient or observation today?” Then ask them to write the answer down for you.

Use federal resource locators to find shelter and local housing supports

If you need immediate shelter or housing resources, federal tools can help you locate services by ZIP code, city, or state.

If you are an older adult, or you are helping a senior, the Eldercare Locator can connect you to local Area Agencies on Aging and services that may include benefits counseling, caregiver support, and local housing-related guidance.

The CDC also summarizes options for finding local homeless assistance resources and points to federal directories.

Build a short, realistic “48-hour plan”

If you are being discharged today and the system is moving fast, focus on what you need to stay safe for the next 48 hours while longer-term housing is arranged:

• Where will you sleep tonight and tomorrow night?
• How will you store medications safely and take them on schedule?
• How will you get food and water that match your medical needs?
• How will you get to your next appointment, wound check, or lab visit?
• Who can be your emergency contact, even if it is a clinic or outreach team?

Bring this plan to the discharge planner and ask them to help fill gaps.

FAQ

• What is a medical respite program?
  It is short-term residential recovery care for people experiencing homelessness who are stable enough to leave the hospital but not well enough to heal on the street or in a shelter.
• Is recuperative care for homeless patients the same as medical respite?
  Yes. Many communities use “recuperative care” and “medical respite” to describe the same type of post-hospital recovery program.
• I was discharged from the hospital with no housing. What should I do first?
  Ask to speak with the hospital case manager or social worker immediately, say you do not have a safe place to recover, and ask for a medical respite referral and a discharge planning evaluation.
• Who qualifies for recuperative care homeless programs?
  Eligibility varies, but programs often accept people who are experiencing homelessness, do not need hospital-level care, and can safely participate in the program setting.
• Does Medicare pay for medical respite or recuperative care?
  Medicare rules focus on medically necessary healthcare services, not housing. Coverage for medical respite varies by community and funding source, so the best next step is to ask the hospital team to check local options and eligibility.
• What if I disagree with the discharge date as a Medicare patient?
  You may be able to request a fast appeal. Ask for the “Important Message from Medicare” notice and the QIO contact information listed on your paperwork.
• What should I bring to medical respite intake?
  If possible, bring your discharge papers, medication list, prescriptions or medications, ID, insurance cards, and any mobility aids or medical equipment you use.
• How do I find housing after hospitalization if I am a senior with Medicare?
  Ask the hospital social worker about local housing navigation, use federal shelter and housing resource locators, and consider contacting your local Area Agency on Aging through the Eldercare Locator for help after a hospital stay.

References

• Medicare: Fast appeals (hospital discharge and other settings)
  https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/fast-appeals
• CMS: An Important Message from Medicare about Your Rights (IM) notice (PDF)
  https://www.cms.gov/files/document/cmsr193pdf
• Legal Information Institute (Cornell): 42 CFR § 482.43, hospital discharge planning requirement
  https://www.law.cornell.edu/cfr/text/42/482.43
• Medicare: Skilled nursing facility (SNF) care coverage
  https://www.medicare.gov/coverage/skilled-nursing-facility-care
• Medicare: Medicare Coverage of Skilled Nursing Facility Care (PDF)
  https://www.medicare.gov/publications/10153-medicare-coverage-of-skilled-nursing-facility-care-508.pdf
• CMS MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing (PDF)
  https://www.cms.gov/files/document/skilled-nursing-facility-3-day-rule-billing.pdf
• National Health Care for the Homeless Council: Medical Respite overview
  https://nhchc.org/medical-respite/
• NHCHC: Defining Characteristics of Medical Respite Care (PDF)
  https://nhchc.org/wp-content/uploads/2025/05/Defining-Characteristics-of-Medical-Respite-Care-handout.pdf
• NHCHC / NIMRC: Models of Medical Respite Care (2025) (PDF)
  https://nhchc.org/wp-content/uploads/2025/03/Models-of-Medical-Respite-Care_2025_final.pdf
• NIMRC: Medical Respite Literature Review (March 2021) (PDF)
  https://nimrc.org/wp-content/uploads/2021/08/NIMRC_Medical-Respite-Literature-Review.pdf
• PubMed: Buchanan D, et al. The effects of respite care for homeless patients: a cohort study (PMID: 16735635)
  https://pubmed.ncbi.nlm.nih.gov/16735635/
• NIMRC: Medical Respite Care Program Planning and Development Guide (2023) (PDF)
  https://nimrc.org/wp-content/uploads/2023/05/MRC-Program-Development-Guide_2023.pdf
• HUD: Find Shelter tool
  https://www.hud.gov/findshelter
• HUD: HUD Resource Locator
  https://resources.hud.gov/
• Administration for Community Living: Eldercare Locator
  https://eldercare.acl.gov/home
• CDC: Homelessness and Health, additional resources
  https://www.cdc.gov/homelessness-and-health/php/resources/index.html

This information is for general education and does not replace medical advice from your own clinicians or care team. If you are considering PACE or have questions about PACE program food benefits, talk directly with your local PACE organization or a trusted advocate.