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8 Ways to Help Ensure a Successful Hospital-to-Home Transition

A caregiver's guide to a safe hospital-to-home discharge

By Leslie Kernisan, M.D., Caring.com senior medical editor, and Paula Spencer Scott, Caring.com senior editor
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Most people aren't fully recovered when they leave the hospital -- far from it. The period between hospital discharge and recuperating at home is critical for your loved one. Yet this hospital-to-home transition doesn't always go smoothly. About 20 percent of Medicare patients are rehospitalized within 30 days, but experts believe that as many as half of those readmissions are preventable.

That's why preparation for this transition is key. The following steps will help you help your loved one successfully negotiate going from hospital to home:

  • Be an active presence in the discharge planning process.

  • Make sure you understand why your loved one was in the hospital.

  • Plan to provide extra help and support to your loved one during the recovery period.

  • Understand what symptoms and signs your loved one should be monitored for, and who to call if you have concerns.

  • Make sure the discharge instructions are clear regarding medications.

  • Prepare the home for your loved one's recovery.

  • Understand what home health services will be provided.

  • Make sure follow-up has been arranged with a primary care doctor or other outpatient health provider.

Be an active presence in the discharge planning process.

Why: Since you're the expert on your loved one and will likely share in the burden of care, your input is essential. To plan for a safe discharge, most hospitals use dedicated professionals known as discharge planners. They usually have a background in either nursing or social work. Other facilities use case managers or other administrators, and, in some cases, a discharge team confers.

What you can do:

  • Be sure to meet with the discharge planner(s). The hospital team will need to understand, for example, what kind of help the patient normally receives at home. Because almost all older adults need extra assistance during the days to weeks following a hospitalization, the hospital team will also need to know how much extra help and supervision family and other caregivers can provide.

  • Be candid. If you feel the hospital team is expecting you to take on a degree of caregiving that you aren't comfortable with, be sure to speak up. Usually the hospital team will find a way to address your concerns.

  • Don't be railroaded into plans that aren't workable. By law, you have a right to appeal a hospital discharge decision you doubt is right. The law also requires hospitals to tell you how to appeal and to explain the appeal process.

Make sure you understand why your loved one was in the hospital.

Why: If you need to get medical help once your loved one is back home, you want to be prepared to quickly explain the medical situation, which can be critical if emergency-room staff or other doctors don't have the case history immediately at hand (and they almost always won't). It sounds basic, but this critical knowledge is often overlooked. Understanding why your loved one was hospitalized can also help you understand what symptoms to look out for once you're home, along with what to expect in the future.

What you can do:

  • Ask the hospital doctor to briefly summarize why your loved one was hospitalized, and write down the key points. You should be able to repeat the key points back to the doctor.

  • When your loved one is given his or her discharge paperwork, review the summary and make sure you don't have additional questions. (Note that these summaries often aren't detailed or informative; that's why you should be sure to talk to the hospital doctors as well.)