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How Do You Transition a Patient From Acute Care to a Home Setting?
Date Updated: December 7, 2024
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Sarah has produced thousands of articles in diverse niches over her decade-long career as a full-time freelance writer. This includes substantial content in the fields of senior care and health care. She has experience writing about wide-ranging topics, such as types of care, care costs, funding options, state Medicaid programs and senior resources.
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Dr. Brindusa Vanta is a health care professional, researcher, and an experienced medical writer (2000+ articles published online and several medical ebooks). She received her MD degree from “Iuliu Hatieganu” University of Medicine, Romania, and her HD diploma from OCHM – Toronto, Canada.
You transition a patient from acute care to a home setting after a thorough assessment and careful planning. Alongside a discharge plan, health care professionals must create a personalized care plan and ensure the provision of all necessary support, which may include home care and home health care services.
Discharge Planning Process
Before leaving an acute care setting, such as a hospital or specialized rehabilitation unit, individuals must undergo a detailed assessment. Evaluations take into account various factors, including expected recovery, mobility and physical, emotional and cognitive state. Professional discharge planners create ongoing care plans before an individual leaves acute care to promote smooth transitions. For continuity, they coordinate with local support agencies, families and the patient.
Medical social workers also participate in the discharge process, connecting seniors and their loved ones with helpful resources in their community. For those with clinical or therapeutic needs, home health care agencies develop service plans providing skilled nursing and rehabilitative services visiting in an individual’s residence. Home care agencies tailor support plans to meet a senior’s nonmedical needs, such as assistance with personal care tasks, housekeeping and transportation. Doctors complete discharge paperwork and arrange follow-up appointments.
In-Home Support Services
Following their return home, individuals receive services tailored to meet their individual needs and preferences. Support may include:
- Intermittent skilled nursing and medication administration
- Physical, speech-language and occupational therapies
- Nutritional guidance
- Home health or home care personal care aides
- Domestic assistance such as housework, laundry, meal preparation and errands
- Companionship services
- Medical and nonmedical transportation
- Home modifications and assistive devices
- At-home medical equipment, including hospital beds, mobility aids and commodes
- Telehealth services
- Counseling
- Pharmacy coordination
- Home-delivered meals
- Family education and training