The discharge planner says Thursday. Your mother lives alone in a two family with eleven steps to the front door and a bathroom on the second floor. She could manage all of it three weeks ago. She cannot manage any of it now.

So you ask the obvious question, and nobody gives you a straight answer.

Can a hospital discharge someone to a home that is not safe?

Mostly, yes. A hospital discharges you when you are medically stable enough to leave. It is not required to guarantee that your house works for you, and in practice it usually cannot know whether it does.

That is the gap families fall into. The clinical question and the practical question are different questions, and only one of them is anybody's job at the hospital.

But you are not without options, and one of them has a hard deadline that most people miss.

What is the Important Message from Medicare?

A notice the hospital gives you and asks you to sign within two days of being admitted as an inpatient. It sets out your rights, including the right to challenge a discharge.

On a longer stay you should get a second copy before you leave, up to two days and no later than four hours before discharge.

Most people sign it on day one, in a corridor, and never look at it again. It is the document that matters most and the one nobody reads.

How do I appeal a discharge, and by when?

By midnight on the day you are told you are being discharged. That is the deadline, and it is the reason this page exists, because a family that spends the afternoon arguing with a ward has usually already lost the option.

You appeal by calling the Quality Improvement Organization for your state. They request the records and a physician reviewer decides whether the person is well enough to go home.

Who do I call in Massachusetts?

Acentra Health, 1-888-319-8452. That is the Medicare Quality Improvement Organization covering Massachusetts.

Be careful here, because a lot of what is published locally is out of date. Several Massachusetts advice pages still name Livanta and give 1-866-815-5440. Livanta is now Commence Health, and it covers New York, New Jersey, Pennsylvania, Ohio, California and others. Not Massachusetts. That number will not start your appeal.

We checked this against Acentra's own Massachusetts page rather than repeating what other sites say, because on a midnight deadline a wrong phone number is the whole ballgame.

Does appealing cost anything?

No, and this is the part that surprises people. The review is free, and if the appeal is unsuccessful you are still not responsible for the cost of the 24 hour period while you waited for the decision.

The organization should call you with its decision within 24 hours of having everything it needs. So in practice an appeal buys you roughly a day, sometimes two, at no financial risk.

Should I appeal, or should I fix the house?

This is the question worth actually thinking about, and almost nothing written on this subject asks it.

An appeal is the right move when the objection is medical . She is still running a temperature. The pain is not controlled. She cannot stand without two people. A physician reviewer can act on that.

An appeal will not help when the objection is architectural . Eleven granite steps are not a clinical finding. A reviewer cannot rule that a staircase is too steep, and buying two more days in a hospital bed does not change anything about the house. You arrive at Saturday with the same eleven steps and less time.

If the reason you are frightened is the building rather than the illness, the appeal is not your tool. Solving the building is, and that can usually be arranged in less time than the appeal would have bought you.

What actually makes a home unsafe on discharge day?

In our experience it is rarely the thing the family is focused on. It is almost always one of these five.

• The steps to the front door. The single most common reason a discharge falls apart, and the one nobody checks because everybody pictures the inside of the house.
• A bathroom on a different floor to where the person can now sleep.
• Nobody there for the first night. Not the first week. The first night.
• A bed on the wrong floor and no plan to move one down.
• Discharge instructions nobody heard properly, because they were given to a patient who was still sedated or exhausted.

Four of those five can be solved in a day or two if somebody starts on Tuesday rather than Thursday afternoon.

What can be arranged before Thursday?

More than most families expect, and faster.

• The steps. We bring a motorized stair chair and two trained staff. $200 a visit, and we will tell you in advance if a particular staircase is not safe to work. Full detail on what stair assistance costs.
• The journey home. Wheelchair transport is $115 each way or $230 round trip within five miles. Our aide goes into the building, takes the discharge instructions and gets the person inside the house rather than to the curb.
• The first night and the first week. Home health aide care at $45 an hour, for as few or as many hours as the situation actually needs.

Call as early in the week as you can. Friday afternoons are the busiest slot we have, because that is when hospitals send people home.

Where to go from here

Two different problems, two different places to start.

• If the difficulty is at home. Tell us what the week looks like and we will say what it would take and what it would cost, on the call.
• If the difficulty is getting out of the house. Book a ride and stair assistance here.

Care Remedy Inc, 100 TradeCenter Suite G-700, Woburn, MA 01801. Call 781-957-8076 and ask for the office nearest you: Woburn, Brockton or Springfield. Home health aide care, wheelchair transportation and stair assistance across Greater Boston, the South Shore and the Pioneer Valley.

Sources: Acentra Health, Massachusetts BFCC QIO page · Medicare Interactive, appeals if your care is ending · CMS, Beneficiary and Family Centered Care Quality Improvement Organizations. This article is general information and is not legal or medical advice. Appeal rights and contact details can change, so confirm the current number with Medicare or the hospital's patient advocate before you rely on it.