Are There Any Tips to Help Ease the Hospital to Home Transition?

2 answers | Last updated: Sep 28, 2016
K-genaro asked...

Are there any tips to help ease the hospital to home transition?

Expert Answers

Linda Adler is the director of Pathfinders Medical in Palo Alto, California. She has dedicated her professional life to helping patients and their families find optimal ways to deal with medical challenges. She has worked in all facets of the medical establishment, including primary care, research, and policy settings at UCSF, Stanford, and Kaiser Permanente. Her current focus at Pathfinders includes crisis management, mediation, and advocacy.

That's a great question, because thinking about this before bringing your loved one home will make the transition easier and more successful. I think of the hospital to home transition in three stages:

The first stage occurs when the patient is admitted to the hospital or rehab facility, because that's the time to start planning ahead by asking some good questions about what's down the road. Knowing the answers to the following questions will help you get ready:

  • What's the expected timing of my loved one's discharge?

  • Who is going to be involved in the decision about sending my loved one home (physician, discharge planner, etc.) and how can I best communicate with them before the discharge day?

  • Will I need to continue certain kinds of care at home (PT, OT, nutritionist), and if so, should I consult with the hospital team for recommendations?

  • What kind of continuity of care can I expect and who will help me make the transition?

  • Should I consider hiring a patient advocate or geriatric care manager to assist me with in implementing the discharge plan?

  • What kinds of caregiver services are available and whom should I consider hiring if needed?

The second stage involves getting your loved one safely settled once they return home. This can be stressful because expectations are so high at the same time that both the patient and the family are often emotionally and physically exhausted. So again, getting things in order before the big day is critical. Consider the following:

  • Will I need to arrange special transportation to bring my loved one home?

  • Do I have all the necessary equipment on hand?

  • Do I need to learn about the medications being prescribed and if so, what are the best resources for helping me to do this?

  • How will I ensure that my loved one is eating properly and getting the best nutrition possible?

  • Who is going to take responsibility for bringing our loved one to medical appointments?

  • Do we need to hire a professional caregiver to help us out, and if so, who will conduct the interviews and handle the hiring process?

  • How will we rotate caregiver duties among family and friends to prevent burnout? Who can I delegate to if I feel overwhelmed?

The last stage involves ensuring that your loved one stays at home and that a return to the hospital isn't required. All too often, this stage gets overlooked, due to caregiver fatigue and misunderstandings around proper home care. Make sure to pay attention to the following:

  • What method should I use to make sure things are going well? Consider using checklists, frequent reviews of discharge orders, and accompanying your loved one to medical appointments where you can do a progress check with the medical team

  • Are we on schedule for our medical appointments?

  • Are we keeping up with the recommendations for OT, PT, etc.?

  • Are nutritional guidelines being met?

  • Do I know who to call in an emergency?

  • If professional caregivers are involved, are the lines of communication open to ensure they are meeting expectations for care?

  • Am I overwhelmed? If so, what resources can I call on to help me continue to take good care of my loved one?

As you move through these stages, remember to identify resources for support if you need them and try to take care of yourself by eating right and getting enough sleep. And be sure to schedule time off from your caregiver duties so that you don't burn out, and to ask for help when you need it!

Community Answers

Greg brewer answered...

The most important thing to do when your loved one is coming back home after being in the hospital is to make sure she has access to all of the necessities. This includes prescriptions and good nutrition. It also means contacting your loved one's doctor to schedule the follow-up appointment"”and making sure she goes to the appointment.

If you live too far away or are otherwise unable to assist your loved one personally, make sure someone is there to help her move around and get all she needs while recovering. Professional services, such as Right at Home's Right Transitions (SM)[], can help do this, making your loved one's transition as smooth as possible. Research online and ask your loved one's doctor about programs in your area.