- The hospital’s duties are written into a federal rule for Medicare-participating hospitals, 42 CFR 482.43.
- The discharge evaluation and plan must be developed by, or under the supervision of, an RN, social worker or other qualified person.
- The rule centers on the stay and the handoff at discharge. It does not assign the hospital to run the plan at home.
- A private RN care manager is chosen and paid by the family and works after discharge.
- Get the written plan, the agency names and a follow-up contact before you leave.
In this article
- What is the difference, side by side?
- What does a hospital case manager do?
- What do federal discharge planning rules require?
- Where does the hospital’s role end?
- What does a private RN care manager do after discharge?
- Who does what, from the hospital bed to the first weeks home?
- Is an RN care manager the same as a geriatric care manager?
- What should you ask the hospital case manager before you leave?
- How does WholeHealth Concierge help families after a hospital discharge?
- Frequently asked questions
- Sources
What is the difference, side by side?
| Question | Hospital case manager | Private RN care manager |
|---|---|---|
| Who arranges them | The hospital, as part of its discharge planning process (42 CFR 482.43) | Your family chooses and hires one |
| When they work | During the stay, through discharge and the handoff of medical information (42 CFR 482.43) | From the hospital stay or the first day home, for as long as the family keeps the service |
| Who can do it | The evaluation and plan must be developed by, or under the supervision of, an RN, social worker or other qualified person (42 CFR 482.43(a)(5)) | A registered nurse, whose license you can check on the DCA license search |
| Main focus | What care is needed after discharge, whether it is available, and getting the information to the next provider | Following that plan at home, coordinating doctors and services, and adjusting the plan as needs change |
| How it is paid | Provided through the hospital’s discharge planning process; you do not hire them | Private pay |
What does a hospital case manager do?
The Case Management Society of America describes case management as a collaborative process that includes assessment, planning, care coordination, evaluation and advocacy, and notes that case managers work in hospitals, insurance companies, clinics, home care and rehabilitation facilities. The American Case Management Association, the professional group for hospital and health system case managers, shares a definition with the Commission for Case Manager Certification, whose priorities include “facilitating safe care transitions”.
In practice, MedlinePlus says a social worker, nurse, doctor, or other provider will work with you on a discharge plan, including whether a patient goes home or to another facility. If nobody has introduced themselves, CMSA suggests simply asking, “Can I speak with a case manager?”
“Case managers are healthcare professionals who serve as patient advocates”
What do federal discharge planning rules require of the hospital?
For hospitals that take part in Medicare, the discharge planning rule is 42 CFR 482.43. In plain terms, the hospital must:
- Identify, early in the stay, patients likely to suffer adverse health consequences after discharge without adequate planning, and evaluate them, or any patient who asks, or whose representative or physician asks.
- Evaluate the likely need for post-hospital services, such as home health, hospice and nursing facility care, and whether those services are available.
- Discuss the results of that evaluation with the patient or their representative.
- Have the evaluation and plan developed by, or under the supervision of, a registered nurse, social worker or other appropriately qualified person.
- When a patient is referred to a home health agency or facility, give a list of Medicare-participating options that serve the area, tell the patient they are free to choose, and identify any in which the hospital has a disclosable financial interest.
- Send the necessary medical information to the providers responsible for follow-up care at the time of discharge.
California adds its own discharge planning requirements. Our guides to your rights if you do not feel ready and appealing a hospital discharge cover them.
Where does the hospital’s role end?
The federal rule centers on the hospital stay and the handoff. Its last step is sending the patient’s necessary medical information, at the time of discharge, to the providers and practitioners “responsible for the patient’s follow-up or ancillary care.” The rule does not assign the hospital’s case manager to visit your loved one at home or to run the plan afterward. From the first night home, the plan belongs to the providers named in it, and to your family.
That is the gap a family often feels: the discharge plan is written, the services are ordered, and then nobody is holding the whole picture. Our guide to coming home from the hospital walks through the first days.
What does a private RN care manager do after discharge?
The Agency for Healthcare Research and Quality describes care coordination as deliberately organizing patient care activities and sharing information among everyone involved in a patient’s care. Its list of specific activities reads like a care manager’s week: establishing accountability, helping with transitions of care, assessing needs and goals, creating a proactive care plan, monitoring and follow-up, and linking to community resources.
An RN brings one more thing to that work. The California Board of Registered Nursing explains that the RN scope includes observation of signs and symptoms of illness, determining whether they are abnormal, and acting through reporting, referral or emergency procedures. After discharge, a private RN care manager can:
- Monitor for changes that the discharge instructions say to watch for.
- Help the family organize medications against the discharge list.
- Coordinate follow-up visits, home health, equipment and the doctors involved.
- Teach the family what the instructions mean in practice.
- Report changes to the right doctor, the same day.
- Advocate for your loved one when the plan is not working.
Who does what, from the hospital bed to the first weeks home?
| Stage | Hospital case manager | Private RN care manager | Family |
|---|---|---|---|
| During the stay | Evaluates what care will be needed and whether it is available | Can join the planning conversation and ask questions with you | Shares what home is really like and who can help |
| Discharge day | Finalizes the plan and sends medical information to the next providers | Reviews the discharge papers and medication list with you | Gets the plan, follow-up dates and phone numbers in writing |
| First week home | The rule assigns no home visits | Monitors, helps with medications and coordinates follow-up | Keeps the medication list current and reports changes |
| The weeks after | The rule assigns no role in running the plan at home | Adjusts the plan as needs change, with the doctors | Decides how much help is still needed |
Is an RN care manager the same as a geriatric care manager?
The work overlaps. A geriatric care manager may come from nursing, social work or gerontology; an RN care manager is a licensed registered nurse doing care management. Our explainer on what a geriatric care manager does covers the broader role, including finances, housing and legal referrals. This guide is narrower: the handoff between the hospital and home.
What should you ask the hospital case manager before you leave?
- Can we have a copy of the written discharge plan?
- Which services were ordered, which agency is providing each one, and when is the first visit?
- Does the hospital have a financial interest in any agency or facility on our list?
- Which medicines are new, changed or stopped? Please highlight them.
- Who do we call with questions after we get home, by name and number?
- Has the medical information been sent to the doctor and agencies handling follow-up?
Write the answers on our hospital discharge checklist and the medicines on our printable medication list, then hand both to whoever is managing care at home.
Before you leave the hospital
- AskGet the written plan, the agency names and a follow-up contact before you leave.
- Write it downWrite the answers on our hospital discharge checklist and the medicines on our printable medication list.
- Hand it overHand both to whoever is managing care at home.
How does WholeHealth Concierge help families after a hospital discharge?
WholeHealth Concierge provides RN-led care management in Orange County, Los Angeles and the Inland Empire. A registered nurse reviews the discharge papers and medication list with your family, assesses what is needed at home, and writes the care plan. RN care management is private pay, and hours and pricing are set during a free consultation. Meagan's California RN license number is posted on our Orange County RN care management page and our About page, with a link to verify it on the state's license search.
Frequently asked questions
What is the difference between a hospital case manager and a care manager?
A hospital case manager works within the hospital’s discharge planning process: evaluating what care is needed next, helping the family choose post-hospital providers, and handing off medical information. A private care manager is hired by the family and follows the plan at home after discharge, coordinating doctors and services and adjusting the plan as needs change.
Does the hospital case manager follow up after discharge?
The federal discharge planning rule for hospitals centers on the stay and the handoff: at the time of discharge, the hospital must send the necessary medical information to the providers responsible for follow-up care. Ask the case manager who your follow-up contact is, by name and number, before you leave.
Who writes a hospital discharge plan?
Under 42 CFR 482.43, the discharge planning evaluation and discharge plan must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified person.
Can I choose my own home health agency after discharge?
Yes, among Medicare-participating providers. The rule requires the hospital to tell patients they are free to choose among participating Medicare providers of post-discharge services, and says the hospital must not limit the qualified providers available to the patient. If your loved one is in a managed care plan, the rule also requires the hospital to tell you to check which providers are in that plan's network.
Do I need a private RN care manager if the hospital has a case manager?
Not always. The hospital case manager plans the discharge, and the federal rule does not assign anyone from the hospital to run the plan at home. A private RN care manager is one option for families who cannot be there every day, or whose loved one has several doctors and services after discharge.
What does a nurse care manager do?
A nurse care manager coordinates a patient’s care and advocates for them. The Case Management Society of America describes case management as a collaborative process that includes assessment, planning, care coordination, evaluation and advocacy, and says case managers help people understand what they need to do and which resources may be available. As a registered nurse, a care manager also observes signs and symptoms and acts through reporting or referral, as the California Board of Registered Nursing explains.
What happens after hospital discharge?
You go home with a written discharge plan, and from the first night home the plan belongs to the providers named in it and to your family. MedlinePlus says your nurse will give you a list of instructions to follow, and that the plan should include your medicines, appointment dates and who to call with questions or an emergency. WholeHealth Concierge nurses review discharge instructions and organize medications at home in Orange County, Los Angeles and the Inland Empire.
Who decides when a patient is discharged?
The hospital team plans the discharge with you and your family, and you can ask for a review if you think it is too soon. MedlinePlus says a social worker, nurse, doctor or other provider will work with you on a discharge plan and help decide if you go home or to another facility. Medicare.gov says people with Medicare can be involved in decisions about their hospital services, and can ask for a fast appeal if they think they are being discharged too soon.
Sources
Each source below was opened and read on the date shown. Links to WholeHealth Concierge pages describe our own service.
- Code of Federal Regulations, 42 CFR 482.43, Condition of participation: Discharge planning (as amended at 89 FR 94592, Nov. 27, 2024). ecfr.gov. Accessed October 10, 2026.
- Case Management Society of America, “What is a Case Manager?” cmsa.org. Accessed October 10, 2026.
- American Case Management Association, “About ACMA” (mission and ACMA and CCMC definition of case management). acmaweb.org. Accessed October 10, 2026.
- Agency for Healthcare Research and Quality, “Care Coordination.” ahrq.gov. Accessed October 10, 2026.
- MedlinePlus, “Leaving the hospital: your discharge plan.” medlineplus.gov. Accessed October 10, 2026.
- California Board of Registered Nursing, “An Explanation of the Scope of RN Practice Including Standardized Procedures” (NPR-B-03, rev. 01/2011). rn.ca.gov (PDF). Accessed October 10, 2026.
- California Department of Consumer Affairs, License Search. search.dca.ca.gov. Accessed October 10, 2026.
- Medicare.gov, “Fast appeals.” medicare.gov. Accessed October 12, 2026.