You said your Dad had Kaiser. My guess is he is with them via a Kaiser Permanente Medicare Advantage Plan. The advantage plans provide Medicare benefits and then supplemental benefits picking up out of pocket costs patients have with Medicare like inpatient deductible and coinsurance. The Kaiser people or the hospital discharge planning people really fell down on they job. They evidently felt he was stable enough following his surgery and did not send him to a skilled nursing facility for a couple of weeks for post acute care. In the Medicare advantage plans with the government, the health plan is at risk for the cost of care. The plans try to save money on things when they feel services are not necessary such as a skilled care. Again, they screwed up because your dad had a re-admisssion and they hate these kinds of occurences - does not make sense, because they did not arrange care after his first discharge in a way to prevent a re-admisssion. All these plans have nurses called Care Managers - their role is to identify patients at risk for re-hospitalization and then keep track of them very closely either directly with the patient or the family to make sure all medical needs are met, appointments are made and kept, prescriptions filled and prescriptions taken correctly. Call your dad's primary care practice and ask to be directed to the Nurse Care Manager in the practice or the health plan that follows high risk chronically ill patients. They should already have your dad red-flagged for intervention. Good Luck and your are a good son to be there for your dad.