Main help needed at home Skilled nursing, therapy, wound care, or monitoring Bathing, dressing, meals, homemaker help, or companionship Both skilled care and personal help, or not sure Help after hospital, rehab, or emergency-room discharge Memory, supervision, fall-risk, or safety support
Coverage context Original Medicare Medicare Advantage plan Medicaid or dual coverage Private, VA, retiree, or other coverage Not sure
Clinician order or referral status Not discussed yet Discussed, but no order yet Ordered, waiting for agency or approval Agency has started visits Denied, delayed, or unclear
Homebound question Likely homebound or leaving home is very difficult Leaves home only with help or for limited reasons Not homebound Not sure
Daily nonmedical help needed Occasional check-ins or errands Daily personal care or household help Around-the-clock or overnight supervision Caregiver break or respite coverage
Agency search status No agency search yet One agency suggested Comparing agencies Current agency concerns
Family caregiver capacity Strong local support Limited local support or work conflicts Long-distance or mostly remote support No reliable helper yet
Equipment or home safety concern No major concern Some concern Major safety, transfer, fall, or equipment concern
Timing need Needed before or soon after discharge Urgent change at home Routine planning Backup plan for future needs
Use this as a care-at-home planning checklist, not a coverage decision.
Use general planning answers only. Do not enter diagnoses, Medicare numbers, Medicaid IDs, Social Security numbers, claim numbers, account numbers, medication details, or private medical facts into this worksheet.
This planner is educational and organizational. It is not medical, insurance, benefits, legal, tax, or financial advice. Confirm eligibility, covered services, costs, prior authorization, agency availability, and care duties directly with the clinician, plan, Medicare, Medicaid office, agency, or qualified professional.
Official references:
Medicare home health services coverage ,
Medicare Care Compare home health search ,
Medicare and Home Health Care booklet ,
NIA services for older adults living at home ,
Eldercare Locator .
