Why discharge planning matters: Nearly 1 in 5 Medicare patients is readmitted to the hospital within 30 days of discharge. Many of those readmissions are preventable with proper in-home support. CalAIM PCHS can be authorized to begin at discharge — before a family even has time to scramble for help.
Whether discharging from a hospital, skilled nursing facility (SNF), or rehab center, the transition process follows a predictable path — and knowing it helps families advocate effectively.
Step 1 — During Hospitalization
Discharge Planning Begins Early
As soon as a patient is admitted to a hospital or SNF, discharge planning should begin. Federal law requires hospitals to notify patients of their discharge rights and involve them and their families in the plan. Ask to speak with the hospital's discharge planner or social worker as early as possible — ideally within the first 24–48 hours.
Step 2 — Before Discharge
Identify the Right Level of Home Support
The discharge planner, in coordination with the medical team, will assess what the patient will need at home: medication management, wound care follow-up, physical therapy, and daily living assistance. For Medi-Cal Managed Care members, this is the point where a PCHS referral can be initiated. Ask the discharge planner or the patient's MCP care manager about CalAIM Community Supports.
Step 3 — Authorization
PCHS Gets Authorized by the Managed Care Plan
The hospital social worker or the patient's MCP care manager submits a Treatment Authorization Request (TAR) to the Managed Care Plan. For post-discharge situations, plans often expedite this authorization. Once approved, a home care provider like Divine Agape is assigned or selected to deliver services beginning at or shortly after discharge.
Step 4 — Discharge Day
Transition Home with Support in Place
When the patient goes home, their care plan should already be in motion — follow-up appointments scheduled, medications reconciled, and home care services arranged. CalAIM Transitional Care Services (TCS) require the MCP care manager to reach out within 7 days of discharge to check in, connect to primary care, and ensure all services are in place.
Step 5 — First 30 Days
The Critical Recovery Window
The first 30 days after discharge are the highest-risk period for readmission. PCHS caregivers help with personal care, meals, medication reminders, and light housekeeping — keeping the patient safe and reducing the burden on family. If a family caregiver is also exhausted from hospital vigils, Respite can be authorized alongside PCHS to give them relief.
Step 6 — Long-Term Planning
Connect to Ongoing Programs
PCHS is a bridge — often used while IHSS is being applied for or while the patient's long-term needs are assessed. During this period, the care team works to get the patient connected to IHSS, ongoing Medi-Cal home health if needed, and any other long-term supports. Divine Agape can assist with IHSS navigation and coordination.
Understanding who does what helps you know who to contact and what questions to ask.
Hospital Social Worker / Discharge Planner
Coordinates the discharge plan, connects families with community resources, and can initiate referrals to Medi-Cal Community Supports and home care providers.
MCP Care Manager / ECM Lead
Your Managed Care Plan's representative who coordinates authorization of CalAIM Community Supports and follows up post-discharge under Transitional Care Services rules.
Home Care Provider (e.g., Divine Agape)
The agency that delivers PCHS services in the home once authorized. Can be requested by name if contracted with the patient's MCP.
Primary Care Physician (PCP)
Must see the patient within 7 days of discharge per CalAIM TCS standards. Oversees the medical side of recovery and can submit documentation supporting PCHS authorization.
Family Caregiver
Often the hub of care coordination at home. Should be included in all discharge planning conversations and informed of Respite as an option to prevent burnout.
County IHSS Social Worker
If an IHSS application is initiated around the time of discharge, a county social worker will conduct the home assessment. PCHS bridges the gap in the meantime.
For families: Don't wait until discharge day to start asking about home care. The earlier you connect with the hospital social worker and the patient's Managed Care Plan, the more likely PCHS will be authorized and a caregiver will be in place on day one at home.