To arrange in-home care after discharge from Edward Hospital, tell the nurse, case manager, or social worker before discharge that the patient is returning home and needs help. Ask for the written discharge plan, any needed home-health referral or therapy order, equipment arrangements, medication instructions, and follow-up appointments. Then arrange non-medical caregiving separately if the person will need help with bathing, meals, mobility, toileting, transportation, or supervision between clinical visits.

Edward Hospital is at 801 S. Washington St. in Naperville and is part of Endeavor Health. Endeavor Health says its hospital care teams include social workers and case managers who help coordinate discharge planning and needed resources. The nurse reviews personalized discharge instructions before the patient leaves. (Endeavor Health: Hospital Medicine; Edward Hospital location; Endeavor Health: About)

1. Start before the patient leaves Edward Hospital

Do not wait until the patient is home to discover that no one can help with stairs, meals, bathing, prescriptions, equipment, or transportation to follow-up appointments.

You can say:

“We plan for my mother to recover at home. Please help us confirm what skilled services, equipment, and follow-up care are ordered, and what help they will need with daily activities when they first get home.”

Ask the nurse, case manager, social worker, or hospitalist for:

1. A copy of the discharge instructions and current medication list.
2. The name and contact information for the clinician or office to call with post-discharge questions.
3. A home-health referral if a clinician recommends skilled nursing, physical therapy, occupational therapy, speech therapy, or a home health aide.
4. Orders and delivery details for necessary equipment.
5. Follow-up appointments and information about transportation.
6. Written activity restrictions and instructions for family members and caregivers.

The Agency for Healthcare Research and Quality’s Be Prepared To Go Home Checklist encourages families to ask what help is needed at home, whether someone should be present, whether nursing or therapy is needed, what equipment is required, which medicines have changed, and who to call with concerns.

2. Choose the right type of post-hospital care at home

“Home care” can mean different services. A two-track plan can make it easier to determine what the patient needs.

Skilled home health is clinical care ordered by a health professional. The Illinois Department of Public Health describes home health agencies as organizations that provide skilled nursing and at least one additional home-health service under a treatment plan prescribed by a physician, podiatrist, or other health professional. Endeavor Health lists skilled nursing, physical therapy, occupational therapy, speech therapy, home-health aide services, and medical social services among its home-health offerings. (Illinois Department of Public Health: Home Health Agencies; Endeavor Health: Home Health)

Ask about skilled home health when the discharge plan calls for services such as wound care, injections, IV therapy, health monitoring, or physical, occupational, or speech therapy.

Non-medical home care provides daily-living support. Illinois describes home services as non-medical assistance with activities of daily living, housekeeping, laundry, and companionship in a person’s residence. This may include help with bathing, dressing, toileting, meal preparation, light housekeeping, errands, reminders, mobility assistance within the care plan, companionship, or transportation. (Illinois Department of Public Health: Home Services Agencies)

A patient may need both. For example, a home-health clinician may make ordered clinical visits while a separate non-medical caregiver helps with meals, personal care, and daily routines between visits. The hours and services should be based on the discharge instructions, the person’s needs, and the provider’s assessment.

3. How to arrange care after a fall at home in Naperville

For an older adult recovering at home after a fall, start by asking the discharge team whether skilled nursing, physical therapy, or occupational therapy is ordered. Then consider non-medical home care for personal care, meals, mobility support, and supervision during the hours when family cannot be there.

The service match may look like this:

• Physical or occupational therapy: Ask the clinician whether therapy is appropriate for the patient’s mobility, balance, transfers, or daily activities.
• Home-health nursing: Arrange this only when it is ordered for the patient’s clinical needs.
• Non-medical caregiving: A caregiver may help with dressing, bathing, meals, reminders, routines, and accompaniment to appointments. This support does not replace a nurse or therapist.

The Illinois Department on Aging lists walking and moving around the home or community, personal care, transportation, medication reminders, and fall prevention among common in-home personal-care needs. (Illinois Department on Aging: In-Home Care)

4. Confirm payment, agency fit, equipment, and the first visit

Medicare coverage is not the same as round-the-clock caregiving coverage. Medicare generally requires a clinician’s order, a Medicare-certified home-health agency, a need for part-time or intermittent skilled services, and homebound status for covered home health. Medicare does not pay for 24-hour care at home, meal delivery, homemaker services unrelated to the care plan, or personal care when that is the only care needed. (Medicare: Home Health Services Coverage, coverage details checked October 2026.)

Ask each provider:

• Do you serve your loved one’s Naperville, Downers Grove, or nearby address?
• Can you meet the needed start date and hours?
• Which services can staff provide, and what is outside their scope?
• What is the backup plan if a caregiver cannot make a shift?
• What are the rates, minimum shift lengths, cancellation policy, and payment options?
• With permission, will you coordinate with the family and home-health team?

For skilled home health, patients have a right to choose their provider. Medicare says the ordering provider should provide a list of agencies serving the area and disclose any financial interest in an agency on that list. Families can compare Medicare-certified agencies using Medicare Care Compare.

For equipment, Medicare Part B may cover medically necessary durable medical equipment when a clinician orders it for use at home. Examples include walkers, wheelchairs, commode chairs, hospital beds, and oxygen equipment. After the Part B deductible, the beneficiary generally pays 20% of the Medicare-approved amount. (Medicare: Durable Medical Equipment Coverage, coverage details checked October 2026.)

Confirm the delivery date for equipment and ask when the first clinical visit is expected, if one was ordered. The home-health agency will schedule an appointment to discuss the patient’s needs and health and coordinate with the ordering provider.

5. Hypothetical example: building a first-week plan

Hypothetical example (no names): A parent is discharged after a fall with a walker and a physical therapy order. Before leaving Edward Hospital, the family confirms the physical therapy referral, follow-up appointment, medication list, equipment delivery, and the correct contact for questions. They schedule a non-medical caregiver during the hours family members are at work. The caregiver helps with settling in, meals, dressing, and getting to follow-up care, while the physical therapist handles the ordered therapy plan.

Each evening, the family checks that prescriptions are available, equipment is in place, the next day’s appointments are confirmed, and everyone knows whom to call with concerns.

This is a planning model, not a universal schedule. The appropriate hours and duration depend on the discharge instructions, home layout, family availability, and provider assessment.

6. Success checks and common planning mistakes

The plan is ready when:

• The family has the discharge paperwork and medication list.
• The first clinical visit, if ordered, has a date or start window.
• Equipment has been ordered and delivery is confirmed.
• A family member or caregiver is assigned for arrival home and coverage gaps.
• Follow-up appointments and transportation are on the calendar.
• Everyone knows the clinical contact number on the discharge paperwork.

Avoid these mistakes:

• Assuming a non-medical caregiver can provide nursing, therapy, medication administration, or wound care.
• Assuming Medicare covers ongoing personal care or 24-hour supervision.
• Scheduling help without sharing relevant discharge instructions and activity restrictions.
• Leaving equipment delivery or prescription pickup unconfirmed.
• Treating a family member’s availability as a plan without assigning specific times and tasks.

If the discharge plan shows that a loved one needs non-medical support at home, ComForCare Naperville & Downers Grove can discuss transitional care and a care plan for personal care, light housekeeping, respite, and support after a hospital stay. This independently owned and operated office serves families in the local area. Call (630) 536-8501 to discuss the help needed and care schedules, from a few hours a week to 24-hour care. Services vary by location.

Each office is independently owned and operated and is an equal opportunity employer.