The first night home, in 25 seconds.
Hospital to home care is non-medical help for the first days after a hospital discharge. Our caregivers help your parent settle in, cook meals, and get through bathing and dressing, with medication reminders along the way. We can usually start within a day or two, often the same day, and we can talk through overnight help for the first nights.
The hospital team starts planning a discharge during the stay, so the best time to line up help at home is before your parent leaves. You can call us from the hospital room.
Why are the first days and nights home the hardest?
Going home is good news, and it is also a risky stretch. The patient safety site of AHRQ, the federal Agency for Healthcare Research and Quality, still cites an older study on this, published in 2003. In it, nearly 20 percent of patients had an adverse event, such as a bad reaction to a medicine, within three weeks of leaving the hospital. AHRQ says medicine problems are the most common complication after discharge.
- A new medicine list. Medicines are often added or changed during a hospital stay. If no one checks the new list against the old one, a missed or doubled dose can happen at home.
- Weakness and falls. AHRQ notes concern that the stress of a hospital stay may leave people weak and more likely to fall. If the stay began with a fall, the CDC says falling once doubles the chance of falling again.
- Confusion. A hospital stay and older age both raise the risk of delirium, a sudden confusion that can come and go. MedlinePlus says people with delirium are often less alert at night, and it can last for hours or weeks.
- A trip back. In 2020, about 16 in 100 hospital stays for Medicare patients 65 and older led to another admission within 30 days, according to AHRQ data.
That is why the first nights are a good time to have another set of hands in the house. If balance is the big worry, read about how our caregivers lower the risk of falls.
What will a caregiver do in the first week?
The help is practical and non-medical. During home care after a hospital discharge, it can include:
- Helping your parent get settled at home, with an eye on safety and fall protection.
- Getting in and out of bed or a chair, and walking with someone close by.
- Bathing, dressing, grooming and help with the toilet.
- Meal preparation, help with eating, and grocery shopping.
- Medication reminders at the times on the discharge list. These are reminders only.
- Light housekeeping, like laundry and dishes.
- Picking up new prescriptions and running errands.
- Going along to follow-up doctor appointments, with limited transportation.
- Companionship through the long, slow days.
If bathing is the hardest part, see our page on hands-on help with showers and getting dressed.
How soon can someone be there?
Care can usually start within a day or two, and often the same day. Calling while your parent is still in the hospital gives us the most time to plan.
For the first nights, ask us about overnight help, so your parent is not alone after dark. We will go over the schedule with you during the free in-home consultation. Plan the most help for the first nights, then look at the schedule again as your parent gets stronger.
What stays with the doctor and the home health team?
We do not provide medical care. Our caregivers do not change wound dressings, give injections, start IVs, do therapy, or give medicines. If your parent needs that kind of care, the doctor may order Medicare home health.
Under Medicare’s home health rules, your parent must be homebound and need part-time skilled care. A doctor or other provider must see them in person and order it. A Medicare-certified home health agency then provides it, and covered services cost nothing. Medicare does not pay for 24-hour care at home, or for personal care when that is the only care a person needs.
We are not Medicare home health, and we work alongside it. A nurse or therapist visits as the doctor orders, and a caregiver can cover the hours in between.
| Our caregivers | Medicare home health | |
|---|---|---|
| Who sets it up | Your family calls us | A doctor orders it |
| What it covers | Bathing, dressing, meals, reminders, walking, errands | Skilled nursing, wound care, injections, IV therapy, physical therapy |
| How much time | Visits or longer shifts | Part-time visits |
| Who pays | Your family, privately | Medicare, for people who qualify |
How do you set it up before discharge?
The best time to plan home care after hospital discharge is while your parent is still in the hospital. Here is a simple order to follow:
- Call (210) 405-4059 from the hospital room, or ask a family member to call.
- Book the free in-home consultation, so we can see the home and talk through what your parent needs.
- Ask the hospital team the questions on Medicare’s discharge planning checklist. Medicare counts you, the caregiver, as part of the planning team.
- Pick up prescriptions and food for any special diet before your parent leaves, so you skip extra trips.
Have these ready when we talk:
- The discharge date and the time your parent should be home.
- The written discharge instructions, including how active your parent can be.
- The full drug list, with new, changed and stopped medicines marked.
- Follow-up appointments, with each date and phone number.
- Any equipment ordered, such as a walker or shower chair.
Ask the staff to show you any task that takes special skill, then practice it. Also ask which warning signs mean call the doctor and which mean call 911.
Are you a case manager or discharge planner?
If your patient needs home care after hospital discharge or a rehab stay, for daily living rather than skilled care, call our office at (210) 405-4059. Start times are usually within a day or two, and often the same day. A caregiver can work alongside the home health agency the doctor orders.
To get started, we need the family’s contact, the discharge date and the home address, plus any activity limits in the orders. A phone call is the fastest way to reach us.
We serve families across Bexar, Comal, Guadalupe and Kendall counties from our office in Bulverde. You can check the towns we cover around San Antonio. We are private pay, so the family makes the decision and pays us directly.
How do families pay for this help?
Families pay us directly for home care after a hospital discharge. Original Medicare does not pay for personal care when that is the only help a person needs.
Read any long-term care insurance policy closely. The National Institute on Aging says these policies can cover help with daily activities at home. Policies differ on who can provide that care, so call the insurer and ask how a home care claim works.
VA Aid and Attendance adds a monthly payment to a VA pension for qualified veterans and survivors who need help with daily activities like bathing, feeding and dressing. We are not a VA provider and do not bill the VA, but we can help your family understand the application. Plan for a wait, since approval can take months longer than VA’s published averages. Families can start private-pay care while VA benefits are pending.
Where does our agency fit?
Assisting Hands Home Care of Northeast San Antonio is a non-medical, private-pay home care agency. Nancy Wilch, MSN, RN, and Troy Wilch are the co-owners. Our office is at 32685 US Highway 281 in Bulverde.
This page covers the discharge moment: the first days and nights after a hospital stay. For a parent coming home from an operation, read about caregiver help while healing from surgery.
Common questions
What if my parent will be home alone?
Tell the discharge planner before your parent leaves. Medicare’s checklist asks caregivers to raise the help they need with staff before discharge. Ask us about overnight help for the first nights home.
Can a caregiver go to the follow-up appointment?
Yes. Going along to doctor appointments is one of our services, and we offer limited transportation. Bring the drug list and the written discharge instructions, as Medicare’s checklist suggests.
Do we need a doctor’s order to start?
No. Private-pay, non-medical help does not need a doctor’s order, so your family can call us directly. Medicare home health is different: a doctor or other provider has to see your parent and order it.
Is your parent coming home from the hospital soon? Call (210) 405-4059 or use the chat on this page for a free in-home consultation.
Reviewed by Nancy Wilch, MSN, RN, co-owner of Assisting Hands Home Care of Northeast San Antonio.
