Discharge day feels like graduation. It's actually the highest-risk handoff in the whole journey: one day you have nurses, therapists, and a call button; the next you have a folder of paperwork and a ride home. The difference between a smooth landing and a crisis-filled first month is almost always the questions asked — or not asked — in the two weeks before discharge.

Bring this list to your discharge planning meeting. You're entitled to clear answers to every item. If an answer is "we'll figure that out later," push back — later is too late.

🖨️
Want this as paper? The printable First 30 Days Packet includes an equipment checklist, caregiver training sign-off, and insurance appeal script that pair with this guide.

The single most important question

For every system below, ask one thing: "After I leave, exactly who manages this — name and phone number?" In the hospital, somebody owns every problem. At home, anything without a name attached becomes nobody's job until it becomes an ER visit.

Bladder

  • Who manages my bladder program after discharge — urology, physiatry, or primary care? When is my first appointment? (Bladder management guide)
  • What exact catheter type and size do I use, who supplies them, and is the reorder set up? How many do I get per month, and what do I do if that's not enough?
  • What are my UTI warning signs, and what's the plan when one starts — who do I call before going to the ER? (UTI guide)
  • When is my first kidney/bladder imaging follow-up (ultrasound/urodynamics)?

Bowel

  • What exactly is my bowel program — timing, meds, technique — written down? (Bowel management guide)
  • Who do I call when it stops working (constipation >2 days, repeated accidents)?
  • Which supplies do I need and who pays for them?

Skin

  • Show me (and my caregiver) how to do a full skin inspection. What's my pressure-relief schedule in the chair and in bed? (Pressure injury guide)
  • Who do I send a photo to if I find redness that won't fade — and how fast will they respond?
  • Has a seating evaluation been done for my cushion, or am I going home on a default?

Medications

  • Walk me through every medication: what it's for, dose, timing, what happens if I miss one, which ones can't stop suddenly (e.g., baclofen).
  • Are all prescriptions filled before I leave? Who refills each one after?
  • Which over-the-counter meds are dangerous for me now (e.g., decongestants with blood-pressure effects)?

Equipment & DME

  • What equipment is ordered, what's only recommended, and what got denied? For every denial: file the appeal before discharge — use the appeal script.
  • Is the wheelchair mine and fitted to me, or a rental/loaner? When is the permanent chair due?
  • Who repairs the chair when it breaks, and what's the loaner plan during repairs? (Equipment guide)

Home setup

  • Has anyone assessed my actual home — entrance, doorways, bathroom? Can OT do a home evaluation before discharge? (Home modifications)
  • What's the minimum safe setup for day one (ramp, bed location, commode), and what can wait?
  • Are there grant or waiver programs for modifications in my state? (State directory)

Follow-up care

  • Before I leave, I want dated appointments (not "call to schedule") with: physiatry, urology, primary care, and outpatient PT/OT. (Why outpatient therapy matters)
  • Who coordinates between all these providers? (If the answer is "you," ask for a care manager referral.)
  • What symptoms mean "call the clinic" vs "go to the ER"? Get it in writing.

Transportation

  • How am I physically getting home — and does that vehicle work for my chair?
  • How do I get to follow-up appointments? Ask about paratransit eligibility, Medicaid non-emergency medical transportation, and accessible ride options. (Adaptive driving for the longer term)

Caregiver training & help at home

  • Has my caregiver done hands-on, supervised training on transfers, skin checks, bladder, bowel, and AD response — at least twice each? Use the sign-off sheet.
  • Ask a CNA to teach us a proper bed bath with warm water and washcloths before we leave — it's gentler on skin than wipes and caps, and it's the skill you'll want on every no-shower day. Far easier to learn here than to figure out at home.
  • Do I qualify for home health (nursing, aide hours, home PT/OT)? How many hours, starting when, through which agency?
  • Can a family member be paid as my caregiver through a Medicaid waiver? Who helps us apply? (Caregiver Hub)

Emergency planning

A red flag worth naming

🚩
If the team can't answer "who manages my bladder/bowel/skin after discharge," you are not ready to be discharged — and neither are they. You can say, in those words: "I don't believe this discharge is safe yet, and I'd like that documented." Ask the case manager about appealing the discharge date with your insurer; hospital discharge decisions can be appealed too, and the words "unsafe discharge" get attention.

What nobody tells you

  • The folder they hand you is written for clinicians, not you. Before you leave, make someone translate it: "Show me the three things in here that will actually matter this week."
  • The first two weeks home are harder than rehab. Everyone's exhausted, the house doesn't work right, and the safety net is gone. That's normal, it improves, and asking for help early is a skill, not a failure. (Mental health guide)
  • Write down every promise. "Home health will call you" and "the chair arrives in two weeks" evaporate unless you have a name, a date, and a number to chase.

Sources & Further Reading

This page draws on lived SCI experience and published clinical guidance, including:

SCI.help articles are information, not medical advice. Practice varies by injury level, provider, and institution — always confirm specifics with your own care team.

Related reading