Piedmont Atlanta Hospital on Peachtree Road is the primary acute care hospital for Buckhead and many of the surrounding neighborhoods, Virginia-Highland, Morningside, Lenox Park, and beyond. It is a world-class facility. It is also a place where discharge planning can move very quickly, and families often feel underprepared for what comes next.

This guide is for those families. It covers the discharge process, the questions you should be asking, what Medicare will and will not cover, and how to have in-home support arranged before your loved one walks out the door.

How hospital discharge planning typically works at Piedmont Atlanta

Most patients are assigned a social worker or case manager within the first 24 to 48 hours of admission. This person is responsible for coordinating the discharge plan, determining what level of care the patient will need after leaving, and arranging the appropriate services.

In practice, discharge conversations can begin earlier than families expect, sometimes just two or three days into a hospital stay. The incentives in the healthcare system push toward earlier discharge, and "discharge planning has begun" does not mean "discharge is imminent," but it is worth paying attention.

The most important thing a family can do is stay engaged with the care team from day one, not just at discharge.

The questions to ask the discharge planner

When you meet with the social worker or case manager, ask these specific questions:

  • What level of care is being recommended after discharge, skilled nursing, home health, or home care?
  • What specific activities is my loved one unable to perform safely on their own right now?
  • What does the physician's discharge order include, any home health services, equipment, or therapy?
  • What medications are changing, and who will explain the new regimen?
  • What are the warning signs that would mean a return to the ER?
  • What follow-up appointments are needed, and in what timeframe?

The difference between home health and home care

This distinction confuses almost everyone. Home health is medical care delivered at home, skilled nursing, physical therapy, occupational therapy, or speech therapy ordered by a physician. Medicare may cover this for a limited period after a qualifying hospital stay.

Home care (what we provide) is non-medical: a trained caregiver who helps with personal care, companionship, meals, medication reminders, and the tasks of daily living. Medicare generally does not cover this. But for most patients coming home from a hospital stay, it is the type of support they need most, and for the longest period.

Arranging home care before discharge, why timing matters

The GoHomeWell program exists specifically for this gap. We prefer to connect with families 48 to 72 hours before a planned discharge so we can review the care plan with the discharge team, prepare the home environment if needed, and have a caregiver scheduled and ready when your loved one arrives home.

Waiting until after discharge to arrange care means at minimum a 24-hour gap, and often longer. For patients coming home with mobility limitations, new medications, or early-stage recovery from surgery, that gap represents real risk.

Call us at (470) 945-4800 as soon as a discharge date is confirmed. We handle the coordination from there.

If your loved one lives alone, in Buckhead, Virginia-Highland, or anywhere in Northeast Atlanta

Discharge planning for a patient who lives alone requires extra attention. The questions to answer before discharge: Is the home safe? Are there grab bars, is the floor clear, is the bed accessible? Is there food? Are medications in place and clearly labeled? Is there someone who will check in regularly for the first week?

Our GoHomeWell coordinators run through exactly this checklist. For patients who live alone, we strongly recommend at least overnight coverage for the first several nights after discharge, when the risk of a fall, a medication error, or a frightening episode is highest.