The period immediately following hospital discharge is often when gaps in the care plan become visible.
This page provides a structured reference to help families confirm what has been arranged and identify appropriate next steps if additional support is needed.
The Maine Senior Care & End-of-Life Registry does not coordinate discharge, provide clinical advice, or manage care plans. This site functions as a public reference and routing layer only.
Confirm that written discharge instructions were provided and include:
• Summary of the hospital stay
• Condition at discharge
• Care plan for home
• Complete medication list
• Follow-up instructions
If any information is unclear, contact the discharging hospital unit directly.
Confirm:
• All current medications are listed
• Any discontinued medications are clearly identified
• New or changed medications are understood
• A pharmacy has been identified
• You know who to contact with medication questions
For clarification, contact the prescribing provider or pharmacist.
Confirm:
• A follow-up appointment has been scheduled or written instructions were provided
• Appointment details (provider, date, location) are documented
• Transportation has been considered
If an expected appointment has not been scheduled, contact the primary care office.
If medical equipment was ordered, confirm:
• Supplier contact information was provided
• Delivery has occurred or timing is known
• Basic use instructions were given
If equipment is missing or not functioning, contact the supplier or discharging provider.
If home health, hospice, or therapy services were included in the discharge plan, confirm:
• The agency received the referral
• A start date or first visit timing has been communicated
• Contact information for the agency is available
If no contact has occurred and services were expected, contact the hospital discharge planner or primary care provider.
Confirm:
• A designated support person understands their role
• Written instructions were provided
• You know who to contact if care needs exceed what can safely be managed at home
If care at home is not manageable, contact the primary care provider to discuss next steps.
Confirm:
• Food, utilities, and a safe living environment are in place
• Transportation for medical needs is available
• Written contact information for non-emergency questions is accessible
For urgent or life-threatening symptoms, call 911.
If new needs arise after returning home, services are organized by geographic section:
Southern Maine
Mid Coast Maine
Central & Western Maine
Downeast Maine
Northern Maine
Within each section, services are organized by care type.
The Registry does not recommend or endorse individual providers. Families are responsible for confirming availability, insurance acceptance, and licensing directly with providers
If care at home becomes unsafe or unmanageable:
Contact the primary care provider or the hospital discharge office to discuss next steps.
For non-urgent planning, review:
Senior Living & Care Facilities
Hospice & Palliative Support
In-Home Care Providers
Search by geographic section.
The Maine Senior Care & End-of-Life Registry is a public, email-based reference infrastructure.
It is not:
• A hospital discharge program
• A care coordination service
• A clinical advisory service
• A referral management agency
• A guarantee of provider availability
All listed providers are independent entities.
For urgent medical emergencies, call 911.