A hospitalization, new diagnosis, fall, memory change, or decline in health can quickly alter a family’s care plan. The change may be temporary, or it may mean that additional help or a different care setting is needed.

You do not have to solve every problem at once. Begin with immediate safety, identify the decisions that must be made now, and ask healthcare professionals and community organizations to help with the next steps.

The Moore County Department of Aging Information and Assistance Program can help older adults and families identify services and make referrals. Call 910-947-4483.

Signs the Current Arrangement May No Longer Be Sufficient

One difficult day does not necessarily mean that a person must leave home. A pattern of changes, however, may indicate that the current level of support is no longer adequate.

Warning signs may include:

• Frequent falls, injuries, or emergency-room visits
• Missed, duplicated, or confused medications
• Difficulty bathing, dressing, eating, walking, or using the bathroom
• Weight loss, dehydration, or spoiled food
• Increasing confusion, wandering, or getting lost
• Leaving appliances on or creating other household hazards
• Unsafe driving
• Missed medical appointments
• Unpaid bills or financial mistakes
• Changes in behavior, judgment, sleep, or personality
• Social withdrawal
• Repeated calls for help
• A caregiver who is exhausted, ill, or no longer able to provide safe care

Begin with a medical evaluation. A sudden change in thinking, behavior, balance, or ability may have a treatable medical cause, such as an infection, medication side effect, dehydration, pain, or another illness.

Call 911 for a sudden or life-threatening change.

Preparing for a Hospital Discharge

Discharge planning should begin early—ideally when the person enters the hospital rather than on the day of departure.

Ask to speak with the hospital’s discharge planner, case manager, or social worker. Explain what help is realistically available at home. Do not say that family can provide round-the-clock care unless that is genuinely possible.

Before discharge, ask:

• What condition is being treated?
• What changes should we expect during recovery?
• What warning signs require a telephone call, urgent care, or 911?
• Which medications were started, stopped, or changed?
• Who should be contacted with questions?
• What follow-up appointments are required?
• Are laboratory tests, wound care, therapy, or medical equipment needed?
• Can the person safely walk, transfer, bathe, dress, eat, and use the bathroom?
• Is home health, rehabilitation, skilled nursing, or personal care recommended?
• Has needed equipment been ordered and delivered?
• Does the person have transportation home and to follow-up appointments?
• What services will insurance cover, and for how long?
• What costs may be the patient’s responsibility?
• What happens if the plan does not work?

Request written discharge instructions and an updated medication list. Make sure the patient and caregiver understand the instructions before leaving.

Medicare provides a printable Discharge Planning Checklist.

If a Medicare patient believes discharge or the termination of covered services is happening too soon, review the appeal instructions in the written Medicare notice immediately. Appeal deadlines can be short.

Care Transitions and Rehabilitation

A care transition occurs whenever someone moves between settings, such as:

• Hospital to home
• Hospital to rehabilitation
• Rehabilitation to home
• Home to assisted living
• Assisted living to skilled nursing
• Hospital or home to hospice care

Transitions create opportunities for information to be missed. Assign one person to maintain the current care summary, including:

• Diagnoses and allergies
• Medication list
• Healthcare providers
• Recent test results
• Treatment and therapy plans
• Advance directives
• Emergency contacts
• Insurance information
• Current physical, cognitive, and personal-care needs

Rehabilitation Options

Rehabilitation may be provided in a skilled nursing facility, inpatient rehabilitation hospital, outpatient clinic, or at home. The appropriate setting depends on medical needs, ability to participate, available support, and insurance coverage.

Ask:

• What are the specific rehabilitation goals?
• How often will therapy be provided?
• What level of improvement is realistic?
• How will progress be measured?
• What equipment or home modifications may be needed?
• Who will train the caregiver?
• When will discharge planning begin?
• What assistance will be needed afterward?

Medicare covers skilled nursing and rehabilitation only when specific requirements are met. Coverage is not automatic simply because a physician recommends rehabilitation. Review current Medicare skilled nursing facility coverage information and confirm coverage with the health plan before admission.

Hold a Family Care-Planning Meeting

A structured family meeting can reduce confusion and prevent the entire responsibility from falling to one person.

Include the older adult whenever possible. Depending on the situation, participants may include family members, close friends, the healthcare agent, financial agent, caregiver, social worker, care manager, or other trusted professionals.

Use a simple agenda:

1. What has changed?
   Review the diagnosis, hospitalization, new limitations, or safety concern.
2. What does the person want?
   Discuss preferences, values, routines, location, independence, and acceptable tradeoffs.
3. What help is needed now?
   Identify medical, personal-care, transportation, meal, financial, supervision, and household needs.
4. What can each person realistically do?
   Assign specific tasks rather than relying on general promises.
5. What professional help is needed?
   Consider home health, personal care, rehabilitation, adult day services, respite, or a different living arrangement.
6. How will costs be handled?
   Review insurance, personal resources, benefits, and each person’s authority to make financial decisions.
7. When will the plan be reviewed?
   Choose a date and identify changes that would require an earlier meeting.

Document decisions and distribute the plan to the appropriate participants. Family members who live far away may contribute by arranging appointments, researching services, managing paperwork, paying for respite, or making regular calls.

Create an Emergency Backup Plan

Every care plan needs an alternative for times when the primary caregiver is unavailable.

Write down:

• At least two backup contacts
• Who can stay with or transport the person
• Where a spare key or access instructions are kept
• Current medications, allergies, and diagnoses
• Healthcare providers and preferred hospital
• Insurance information
• Advance directives and healthcare-agent information
• Mobility, communication, dietary, and behavioral needs
• Care instructions for pets
• What to do if the person wanders or becomes confused
• Where the person could stay temporarily
• Which home-care agency or facility to call
• How essential expenses will be paid

Ask backup caregivers in advance. Do not assume that a relative, friend, or neighbor will be available.

For severe weather, power outages, evacuation planning, and emergency supplies, visit the SAC’s Safety & Preparedness section.

Palliative Care

Palliative care focuses on relief from pain, symptoms, stress, and the practical or emotional burdens of serious illness. It may be appropriate at any stage of illness and can often be provided alongside treatment intended to cure or control the condition.

A palliative-care team may help with:

• Pain and symptom management
• Difficult treatment decisions
• Communication among specialists
• Emotional and spiritual support
• Understanding the likely course of illness
• Aligning treatment with the patient’s goals
• Support for family caregivers

Ask the physician or hospital whether a palliative-care consultation would be helpful. Requesting palliative care does not mean giving up treatment.

Learn more from the National Institute on Aging’s hospice and palliative-care resources.

Hospice Care

Hospice is specialized palliative care for a person approaching the end of life who has chosen to focus on comfort rather than treatment intended to cure the terminal illness.

Hospice services may include:

• Physician and nursing care
• Pain and symptom management
• Medications related to the terminal illness
• Medical equipment and supplies
• Personal-care assistance
• Social-work services
• Spiritual care
• Short-term respite or inpatient care
• Support and education for caregivers
• Grief and bereavement support

Hospice may be provided in a private home, assisted-living residence, nursing facility, hospice facility, or other setting. The family still needs to understand who will provide day-to-day care and what help is available after hours.

Ask a hospice provider:

• What services are provided at home?
• Who responds at night and on weekends?
• How quickly can a nurse visit?
• Which medications and equipment are covered?
• What should the family do during a symptom crisis?
• Is inpatient hospice care available?
• How is caregiver respite handled?
• What bereavement services are offered?
• Which services or treatments are not covered under the hospice plan?

Medicare beneficiaries can review the Medicare hospice benefit and compare certified providers through Medicare Care Compare.

For local information, FirstHealth Hospice can be reached at 910-715-6000. The Village provides this link as a community resource and does not recommend or endorse a particular provider.

Discuss End-of-Life Wishes

When possible, discuss wishes before a crisis makes the conversation urgent.

Topics may include:

• What quality of life means to the person
• Where the person prefers to receive care
• Treatments the person would or would not want
• Cardiopulmonary resuscitation
• Hospital transfers
• Artificial nutrition and hydration
• Comfort and symptom relief
• Religious or spiritual practices
• People the person wants nearby
• Funeral, burial, cremation, or memorial preferences
• Messages, possessions, or unfinished matters important to the person

Review the healthcare power of attorney, living will, and any Medical Order for Scope of Treatment. Make sure the healthcare agent, family, physicians, emergency responders, and care providers have access to the current documents.

Do not wait until the person is unable to participate. A physician, palliative-care specialist, hospice professional, clergy member, or attorney can help guide the conversation.

Visit the SAC’s Legal, Financial & Healthcare Planning page for information about North Carolina advance directives and decision-makers.

What to Do Following a Death

There is no need to complete every administrative task immediately. Begin with the necessary notifications and ask the funeral home, attorney, and trusted family members for help.

Immediately

• If the death was expected under hospice care, call the hospice organization and follow its instructions.
• If the death was unexpected at home, call 911.
• Notify close family members and the person’s legal representative.
• Contact the selected funeral home, cremation provider, or other authorized service.
• Locate advance instructions, military discharge records, and funeral or burial documents.
• Secure the home, pets, vehicles, medications, valuables, and personal papers.

Do not distribute property, close accounts, sell assets, or use the deceased person’s financial credentials unless you have legal authority.

During the Following Days and Weeks

The appropriate executor, administrator, surviving joint owner, or other authorized person may need to:

• Obtain certified death certificates.
• Locate the will and trust documents.
• Contact an estate attorney when appropriate.
• Notify Social Security, pension administrators, employers, and benefit programs.
• Contact life-insurance and annuity companies.
• Notify financial institutions and credit-card issuers.
• Contact Medicare and other health insurers.
• Notify property, automobile, and other insurers.
• Arrange mail forwarding.
• Review automatic payments and subscriptions.
• Protect personal information against identity theft.
• Apply for survivor benefits when eligible.
• Keep records of every notification, payment, and expense.

Funeral homes commonly report a death to Social Security, but families should confirm that the report was made and ask about possible survivor benefits. Visit Social Security’s What to Do When Someone Dies and Survivor Benefits pages or call 800-772-1213.

Certified North Carolina death certificates may be obtained through the Register of Deeds in the county where the death occurred or through North Carolina Vital Records.

A surviving spouse or relative is not automatically responsible for every debt in the deceased person’s name. Do not pay unfamiliar collection demands from personal funds without verifying the debt and obtaining legal advice. The Consumer Financial Protection Bureau explains what to do when debt collectors contact a family after a death.

Grief and Bereavement Support

Grief may involve sadness, anger, relief, guilt, exhaustion, confusion, anxiety, or numbness. There is no single correct timetable or way to grieve.

Support may come from:

• Family and friends
• Faith communities
• Hospice bereavement programs
• Grief-support groups
• Individual counseling
• A primary-care physician
• Mental-health professionals
• Groups for people who have experienced a similar loss

FirstHealth Hospice offers local grief counseling and support through its hospice services. Call 910-715-6000 for current information.

Seek professional help if grief is making it difficult to eat, sleep, manage basic responsibilities, remain safe, or function over time. If you or someone else is in immediate danger, call 911. For confidential crisis support, call or text 988.

Support for a Surviving Spouse or Caregiver

After a death, a caregiver may lose not only a loved one but also a daily role, routine, support system, and source of income. Recovery can include both emotional and practical adjustment.

Helpful first steps include:

• Accept help with meals, transportation, paperwork, and household tasks.
• Avoid making unnecessary major financial decisions immediately.
• Schedule a medical appointment if caregiving affected your health.
• Review income, benefits, housing costs, and insurance coverage.
• Ask about Social Security, pension, veterans’, or employer survivor benefits.
• Update emergency contacts, powers of attorney, beneficiaries, and your own estate plan.
• Reconnect gradually with friends, activities, faith communities, or volunteer opportunities.
• Consider a grief group or counselor.
• Be alert for scams targeting recently bereaved people.

The Consumer Financial Protection Bureau offers a practical guide for surviving spouses managing financial changes.

The Moore County Department of Aging can also help a surviving spouse or caregiver identify local programs, activities, benefits counseling, transportation, nutrition services, and social support. Call 910-947-4483.

Take the Next Step

When care needs change, start with three questions:

1. Is everyone safe today?
2. What decision must be made next?
3. Who can help us make it?

For local information and referrals, contact the Moore County Department of Aging at 910-947-4483. You do not need to have the entire plan figured out before making the call.