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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.)

More ways to ways to help ensure a successful hospital-to-home transition

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

Why: Always assume that someone who's been hospitalized -- whether for a few days or much longer -- will need extra help and supervision during the weeks following hospital discharge. Even under a best-case scenario, it usually takes at least that long for an older adult to get back to his or her usual self. Caregivers often incorrectly assume that home health services will address most of their loved one's daily needs -- but they can't, since home health services come just a few times a week.

What you can do:

  • If your loved one usually lives alone, plan on having someone stay with him or her for at least the first few days, to make sure any dementia hasn't worsened and he or she has recovered enough function to live alone again.

  • Prepare to help with healthcare and personal care. Whether your loved one lives alone or not, after a hospitalization, most people with dementia will need to have the caregiver take on a certain number of added tasks. These may include healthcare tasks such as:

    • Monitoring symptoms, such as pain or shortness of breath.

    • Changing wound dressings.

    • Making sure discharge medications are taken as directed.

    • Administering as-needed medications, such as those for pain or for constipation.

    • Providing catheter or ostomy care.

    • Helping with injections.

    • Supervising physical therapy exercises

    There may also be personal care tasks involved, such as helping your loved one to:

    • Get safely up out of bed.

    • Get to the bathroom.

    • Use a walker or wheelchair.

    • Bathe or shower.

  • Ask hospital staff for advice on how to manage unfamiliar tasks. If these are new tasks that you haven't previously been trained to do, be sure to mention this to the hospital nurses and to the discharge planner. Often families can learn a lot from hospital staff during the last day or two before hospital discharge.

  • Consider enlisting extra help, either from family or from a paid aide. Managing all the home care- and recovery-related tasks involved is both time consuming and emotionally and physically demanding.

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

Why: At discharge, your loved one will be on the mend but still recovering from whatever landed him or her in the hospital. Once home, you'll be the first line of monitoring and care for your loved one. It's essential to have a clear picture in your mind of what to expect in terms of a time frame for improving symptoms, what kinds of setbacks are common, and what are the signs that you need to reengage medical help.

What you can do:

  • Be sure you're present when discharge instructions are reviewed. The symptoms or signs your loved one should be monitored for are usually spelled out in written discharge instructions; most hospitals have a nurse or other provider review the instructions on the day of discharge. Be aware that hospital staff will sometimes review discharge paperwork only with the patient. But hospitalization is taxing even on someone who doesn't have dementia; your loved one will almost certainly be better off if you hear the information, too.

  • If by chance you miss being included in a discussion of discharge instructions, don't hesitate to ask for someone to review the instructions once again with you before your loved one leaves the hospital.

  • Realize that the exact symptoms to watch for will depend on the particulars of your loved one's case. For example, if your loved one was hospitalized for heart failure, you'll probably need to watch for worsening shortness of breath and for weight gain.

  • Ask about the best way(s) to communicate if there's a problem. Just as important as knowing what to watch for is knowing whom to call if a worrisome symptom pops up. Some hospitals employ dedicated nurses or other staff who check on patients post-discharge and are available in case you have concerns. Other hospitals direct patients to call their primary care doctor. If this is the case, make sure the hospital has sent a discharge summary to your love one's primary doctor, so he or she is best prepared to manage the new developments.

Make sure the discharge instructions are clear regarding medications.

Why: Most people with dementia need a caregiver's help with medications even before hospitalization. This reliance will increase after a hospitalization, when mental functioning may be even more confused and new drugs may have been introduced.

What you can do:

  • Be sure you leave with a discharge medication list. This is supposed to include all medications your loved one needs to take for his or her chronic conditions, plus any new medications related to the hospitalization.

  • Compare this list to your loved one's prehospitalization medications. If the hospital staff have discontinued any of your loved one's usual medications, ask for a brief explanation as to why. Be sure you understand the purpose of any new medications, as well as any side effects to watch out for.

  • Specifically ask if any medications your loved one is taking might make thinking or balance worse. It's better to know in advance if these are likely side effects.

  • Talk about instructions for medications that are to be given "as needed." Medications for pain and constipation are often prescribed this way, for example. In most cases, it falls to caregivers to figure out when the medication is needed, and to dole the pills out accordingly. Patients with dementia, in particular, may not think to report pain, and so they may not receive meds when needed.

  • Be sure to bring all post-hospitalization medications to the follow-up visit with the usual primary care doctor. You'll also want to let the usual doctor know how often the "as-needed" medications are being taken.

More ways to ways to help ensure a successful hospital-to-home transition

Prepare the home for your loved one's recovery.

Why: It's better to arrange necessary changes before your loved one heads home, because you'll feel better prepared and the house will seem calm, not stressed. Discharge planners can help you think through what will be needed.

What you can do:

  • Explain the home environment to the discharge planner. Does the person live alone or with others? With you? Where is the person's room? Are there stairs to negotiate? How are meals provided? This information will help you both think through what's needed in the weeks ahead.

  • Explain any limitations that you have. Do you work full- or part-time? Do you have health issues of your own that may limit your ability to provide care? Are you unable to drive? Together with the discharge planner, you may need to address transportation or meal services available in your area.

  • Consider making minor modifications. For example, if the person you care for has any additional physical limitations after the hospitalization, such as need for a walker, will you have to set up a bed on the ground floor? Can you install grab bars in the bathroom(s) to provide added support?

  • Figure out who's paying. Often insurance is able to provide certain equipment after a hospitalization, such as a hospital bed, bedside commode, or shower chair. You may also need supplies, such as gloves or dressings for wound care. The discharge planner should help you figure out exactly what will be needed and who will be expected to pay.

  • Get rid of obvious falling and tripping hazards. You should assume your loved one will be at higher risk for falls because of a weakened state after being in the hospital. If you haven't done it yet, now is a good time to clear area rugs off the floor, make sure the path to the bathroom is well lit, and get secure footwear with nonslip soles.

Understand what home health services will be provided.

Why: Home health services are usually ordered by doctors (who must attest to their medical necessity) after a hospitalization. These are "skilled" services and may include nursing visits, physical therapy, occupational therapy, and more. These services help facilitate your loved one's recovery.

What you can do:

  • Ask to have recommendations written out. The discharge planner should be able to tell you what services have been ordered and what to expect about the nature, timing, and purpose of each. Be aware that the prescribed quantity tends to come nowhere near the level of care that was provided in the hospital or that would be provided in a rehabilitation facility.

  • Ask how these services will be paid for. Most insurance companies (including Medicare) will pay for certain "skilled" services to be provided for a limited time in the home. Home healthcare may not be paid for, however, if the hospital stay was shorter than 72 hours.

Learn more about home healthcare after hospitalization.

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

Why: It's usually a good idea to have a post-hospital visit within two weeks of discharge, to ensure that recovery is going as expected. Follow-up appointments are often listed in the discharge paperwork that your loved one will receive prior to discharge.

Depending on the hospital and the reason for hospitalization, follow-up appointments might be offered at a post-hospitalization follow-up clinic, a specialty clinic, or with your loved one's regular primary care doctor.

What you can do:

  • Don't stop at one quick follow-up. Even if the hospital offers a post-hospitalization phone call or in-person visit, it's essential that your loved one see his or her usual primary care doctor for a post-hospital visit, usually within a few weeks. This will help ensure that any new health information uncovered by the hospitalization gets integrated into your loved one's overall care plan.