Hospital to Home: The Complete Transitional Care Guide

Through Every Step, Every System, and Every Hard Conversation

Written by Stacey Savarese, RN, BSN, BSW, CCM, with 30 years of Healthcare and Case Management experience

Check It. Type It. Save It.

The interactive edition lets you:

✓ Check off discharge concerns
✓ Type notes directly into the guide
✓ Record names, dates, and phone numbers
✓ Save your progress and return later
✓ Jump directly to the section you need

Use it on a computer, tablet, or phone

Nobody prepared you for this.

You are standing in a hospital hallway, and someone just told you your parent cannot go home alone.

Or maybe you do not need to be told. You know instinctively that your parent and family need a plan.

You have hours, maybe only days, to figure out where they go. Who pays for it? What does insurance cover? What do you need to prepare for the short and long term?

This guide was written for exactly this moment. By a Nurse and Case Manager who has spent 30 years on every side of this system: the bedside, insurance, advocacy roles, and the discharge planning side. What you will find here is the insider knowledge most families never get.

Is This Guide For You?

Your parent just got discharged and you do not know what comes next
You are watching your parent decline in the hospital or rehab
Discharge from the hospital seems rushed, and you are not sure why
There seems to be a lot of opinions, but no clear action
You want to advocate for your parent without feeling steamrolled at every turn

See What’s Inside the Guide

Watch a quick walkthrough of the Printable and Interactive versions so you know exactly what you’ll receive.

What's Inside This Guide

Why hospitals rush discharge and how to push back
Acute Rehab versus Skilled Nursing, and how to get the right placement
A home safety assessment before your parent comes home
Medication review, including how to avoid cost barriers
The Four post-discharge options with real cost breakdowns
Medicare, Medicare Advantage, Medicaid, and VA benefits explained
A week by week caregiving calendar for the first six months
The emotional reality of discharge, for your parent and for you
What to do when your parent refuses all help
Palliative Care versus Hospice, explained clearly
How to start the end of life conversation
Talking to an Elder Law Attorney

About the Author

Stacey Savarese, RN, BSN, BSW, CCM has spent 30 years working across every corner of the American healthcare system.

From Geriatric Social Work in Philadelphia to Emergency nursing, ICU, PACU, Home Care, Palliative Care, and Hospice. She was one of the first Case Managers embedded in a Primary Care Patient Centered Medical Home. She later moved into case management at local and national insurance companies, learning exactly how coverage decisions get made. Hospital Utilization Review, fighting alongside physicians to get patients the coverage they needed. And now, Transitional Case Management for high-risk patients moving from hospital to home.

She has sat on every side of the system with families facing a healthcare crisis. Not as an outside observer, but as someone who has worked inside all of it.

The Caregivers Directory was built to share that insider knowledge with the families who need it most.

Get Your Complete Guide Today

Your purchase includes three files delivered instantly to your email.

Print Version. A beautifully designed 69-page PDF, ready to print and keep at the bedside, in the car, or on the kitchen counter. Clean pages you can write on by hand.

Interactive Digital Version. The same complete guide, but built to use directly on your phone, tablet, or computer. Click any chapter in the table of contents and jump straight there. Check off items with a tap. Type your notes right into the page. Enter your numbers into the cost worksheets and watch the totals calculate automatically. Everything you need to track is built right in.

Quick Start Guide. A short two-page walkthrough showing you exactly how to use the interactive features on whatever device you have. Read this one first.

All three arrive in your inbox the moment your purchase is complete. No waiting. No shipping.