Hospital discharge planning starts sooner than most families expect. Here’s how it works in Ukiah and what to ask before you leave. If someone you love is in the hospital, you’ll probably hear the word “discharge” within the first day or two.  Hospital discharge planning starts early so there’s time to work out what comes next, and you get a say in it. 

Redwood Cove Healthcare Center is on South Dora Street, a short drive from Adventist Health Ukiah Valley. Our social services team works with families on discharge planning, both when someone arrives for a short-term stay and when it’s time to go home. Below, you’ll find how the process works, what a discharge plan should cover, and how to choose where you recover. 

What Is Discharge Planning? 

Hospital discharge planning is the work a hospital does to prepare you to leave and arrange the care you’ll need afterward. A discharge plan is the result. It’s a written plan for where you’re going, what medicines you’ll take, and who will follow up. 

Federal rules require hospitals that take Medicare to start this process early. Hospitals have to identify patients who are likely to have problems after they leave, and they have to treat the patient and caregiver as active partners in planning (42 CFR 482.43). They also have to send your medical information along to whoever cares for you next.  So discharge planning shouldn’t be something that’s simply handed to you at the end of your hospital stay. You and your caregiver should be involved throughout the process, helping shape a plan that meets your needs after discharge. 

Who Your Discharge Planner Is 

Most hospitals assign a discharge planner. It’s often a nurse case manager or a social worker, and the title varies from one hospital to the next. If nobody has introduced themselves by the second day, ask your nurse who’s handling discharge planning for your room. 

That person is your main contact for the next step, and they are usually busy. They talk with your doctors, check what your insurance covers, and send referrals to home health agencies or rehab centers. It helps to give them one family member’s phone number as the main contact so updates don’t get lost. 

Not everyone from Mendocino County ends up in the hospital in Ukiah. Some people have surgery in Santa Rosa or are treated at Howard Memorial in Willits. If that’s you, tell the discharge planner early that you’d like to recover closer to home. Hospital discharge planning teams can send referrals to centers here too. 

What a Discharge Plan Usually Includes 

Every plan is a little different. Medicare’s discharge planning checklist, updated in December 2025, is a good guide to what yours should cover. Expect it to answer questions like these: 

• Where you’ll go after the hospital: home, home with home health visits, or a short-term rehab stay 

• Which medicines to take, which ones changed, and which ones to stop 

• Your follow-up appointments, and who’s making them 

• Equipment you’ll need, like a walker or a shower chair 

• Who will help you at home, and what they need to learn first 

• Warning signs to watch for, and who to call 

Ask for the plan in writing. It’s worth asking for a copy for the family member who’ll be helping you, too. 

Home, Home Health, or Short-Term Rehab? 

A lot of people go straight home, and that’s the goal. Some go home with a home health nurse or therapist who visits a few times a week. 

Short-term rehab in a skilled nursing center makes sense when you need more than that. Maybe you can’t get to the bathroom safely on your own yet. Maybe you need therapy most days, or wound care that a nurse has to handle daily. 

At Redwood Cove, rehabilitation includes physical, occupational, and speech therapy, with programs for recovery after surgery, a stroke, or a cardiac event. Our nurses are on-site 24 hours a day. 

Short-term rehab stays usually last a few weeks. Some are shorter, and some run longer. It depends on how your recovery goes, and nobody can promise a timeline on the first day. 

You Get to Choose Where You Go 

This is the part of hospital discharge planning many families don’t know about. When a hospital refers you to a skilled nursing or rehab center, it has to give you a list of the Medicare options available to you. It also has to tell you that you’re free to choose among them and share quality information that fits your goals. 

You can look up any center yourself on Medicare’s Care Compare tool. Visit if you can. Call if you can’t. 

Distance matters more than people expect. A rehab stay in Ukiah means family can stop by after work, and you’re near the doctors and clinics you’ll see once you’re home. If Redwood Cove is your choice, tell the discharge planner by name. You can also call our admissions line anytime, and we’ll coordinate with the hospital. 

Medicare’s 3-Day Rule and What Rehab Costs 

Medicare Part A covers skilled nursing care after a hospital stay, but only if you meet a few conditions. The big one is a qualifying inpatient stay of at least three consecutive days. Time spent under observation or in the emergency room before you’re admitted doesn’t count. You also generally need to start your skilled nursing stay within 30 days of leaving the hospital (Medicare.gov). 

If You Think You’re Leaving Too Soon 

You have the right to appeal, and it is worth knowing how before you need it. You should receive a notice called “An Important Message from Medicare about Your Rights” within two days of admission, and usually again shortly before you go home. It explains how to ask for a fast appeal. 

To use it, follow the directions on the notice no later than the day you’re scheduled to leave. If you do, you can stay in the hospital while an independent reviewer decides. You won’t pay for those days beyond your usual coinsurance or deductibles (Medicare.gov). 

In California, the reviewer is Commence Health, the state’s Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Its helpline is (877) 588-1123. 

What Happens When You Arrive at Redwood Cove 

Hospital discharge planning doesn’t stop at the hospital door. If you choose a short-term stay with us, the handoff starts before you get here. Our admissions team works with the hospital and your family to gather what we need. 

A physician reviews your care shortly after you arrive, and our medical director provides regular oversight. How often you have therapy depends on your condition and your physician’s orders. Many short-term rehab residents work with therapists several days a week, sometimes more than once a day. 

Bring a complete list of your medications, with dosages and the doctors who prescribed them. We usually supply the medicines themselves. Pack comfortable shoes and about a week of comfortable clothes. 

Then the planning starts again, this time for going home. Our social services team handles discharge planning from Redwood Cove too, and helps coordinate outside appointments like dental and vision care. 

Questions to Ask Before You Leave the Hospital 

Good hospital discharge planning leaves room for your questions. Here are the ones worth asking before you sign anything: 

• Am I an inpatient, or am I under observation? 

• Who is my discharge planner, and how do I reach them? 

• Where do you recommend I go next, and why? 

• Which rehab centers did you send my referral to? Can you add one closer to home? 

• Which of my medicines changed, and does my next care team have the list? 

• Who’s scheduling my follow-up appointments? 

• What equipment will I need, and who’s ordering it? 

If you’re thinking about a short-term stay in Ukiah, contact our team or call us.  We’ll answer what we can over the phone and help with the next steps.