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Who Is Responsible for Coordinating Home Care After Hospital Discharge?
Date Updated: December 9, 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.
Several parties are responsible for coordinating home care after hospital discharge. They include designated discharge planners from the hospital, social workers and in-home care providers. Plans also account for the individual's preferences and the opinions of their loved ones.
Professionals Involved in Home Care Coordination and Provision
Although physicians discharge patients from hospitals, discharge planners ensure the creation of appropriate support plans before an individual leaves. Some hospitals have staff who specialize solely in discharging patients, while others designate such responsibilities to a nurse or social worker. Discharge planners, also known as case managers and discharge coordinators, oversee arrangements and connect with relevant agencies, accounting for individuals’ needs, their preferences and local service availability.
Hospital social workers connect older adults and their families with community support resources to ensure seniors’ holistic well-being and smooth transitions from hospital to home. Home care agencies review seniors’ needs and arrange appropriate support services, and doctors schedule checkups to monitor an individual’s recovery and overall health.
Common Home Care Services
Home care services provide hands-on and practical support so that seniors can safely live at home. Often, people returning home after a hospital stay need temporary or ongoing help to manage day-to-day tasks. Depending on tailored care plans, aides assist with domestic chores, errands and personal care tasks, such as bathing, toileting and dressing. They may also provide companionship and transportation.
However, home care doesn’t include medical or therapeutic care. While home care aides may remind seniors to take medications and attend medical appointments, they can’t deliver skilled services. Seniors who require in-home clinical care following a hospital stay often find home health care more appropriate.