Hospital to Home Transition Care


Continuing the Recovery at Home After a Hospital Stay

As a stay at a hospital or rehabilitation facility draws to an end, it is vitally important to establish a plan for ensuring a senior has all the guidance and support necessary to continue healing and recovering at home.

Our care management and caregiver services are an extremely valuable source of support during this important stage of recovery. During this time, our care is centered on helping the senior emotionally adapt to returning home while minimizing the risk of falls, mis-management of medications and missed doctor appointments. These are the leading risk factors causing the high rate of hospital re-admission within the first 30 days of a senior’s return home.

Discharge Planning

Prior to discharge, it is important to thoroughly plan for the return home. We work closely with the discharge planner, the senior and the senior’s family to help understand and plan the following:

  1. Scheduling the providers of in-home medical and therapy care
    1. All prescribed in-home therapy and medical follow up is outlined by the discharge team.
    2. As desired, we will provide referrals and facilitate the necessary scheduling of all prescribed home health care.
  2. Scheduling all in-home non-medical care and assistance
    1. We perform an initial assessment of the non-medical care and assistance required at home.
    2. We carefully match the most appropriate caregiver with the senior and arrange an initial “meet and greet” while the senior is still in the hospital or rehab facility.
    3. A list of supplies needed to continue recovering at home is developed. These supplies often include wheelchairs, walkers, commodes, hospital beds and specialized personal care items. All ordering and delivering is facilitated.
  3. Ensuring home safety
    1. We survey the senior’s home in advance of the discharge and provide recommendations for specific safety improvements. These improvements can include customized adaptations such as grab bars in the shower, raised toilet seats, and shower benches.
    2. As necessary, we will recommend a home safety specialist and coordinate the ordering, delivery and implementation of home safety items.

Coming Home

On the day of discharge all prescribed medications are carefully reviewed and transcribed into an easy to follow medication list – clearly describing the visual appearance of all medications, their purpose, potential side effects and when they are to be taken throughout the day. As necessary, we will also facilitate the refill of all medications so they are available immediately upon returning home.

The first days at home are always an adjustment for the senior no matter how carefully everyone has planned for the discharge. It typically takes 72 hours for discharged seniors to begin feeling comfortable and confident at home again. To facilitate this adjustment period, the senior will already be familiar with his or her caregiver, having met the caregiver prior to discharge. We also coordinate with the senior and/or the family to ensure all groceries are in the home and plan initial meals in accordance with the care requirements and preference of the senior.

Recovery at Home

When home, a typical day during the initial couple weeks of recovery should revolve around five core activities:

  1. Meals/snacks
  2. Medications
  3. Rest
  4. Bathing
  5. Therapy

Our approach to care at home during this time will focus on working closely with the senior, the family and all medical providers to develop a regular routine. Our caregivers will help establish regular meal times, medication reminders, therapy schedules, follow-up medical appointments and more. In addition, the caregiver provides constant monitoring and support that is critical for seniors with mobility or dexterity issues. Finally, our caregiver will enable the recovering senior to focus on rest and recovery by taking on household and other daily responsibilities.

We seek to assist the senior in understanding that recovery is a gradual process. We provide the necessary care and care management to encourage patience through the recovery process while ensuring that the senior is safe, follows all care recommendations and develops a routine which facilitates the most rapid return to the highest quality of life possible.

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