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How to Ease Hospital-to-Home Transitions

April 1, 2025Daniela Momtcheva

When elderly individuals are discharged from the hospital, eager to return to the comfort of home and their usual routines, they often underestimate the challenges of transitioning back to a home environment. These challenges can include safety hazards when navigating the house, mishandling medications, heightened risks of injury from overexertion, and the need for support with basic daily activities. Without adequate care and assistance, this transition can become overwhelming, increasing the likelihood of complications that may lead to readmission within just a few months.

One in five seniors discharged from the hospital returns within 30 days due to various factors. These include inadequate education for both patients and caregivers, rushed transitions, and unclear post-discharge care instructions.

To avoid such an unfortunate turn of events and reduce the risks for hospital readmission, seniors need quality post hospital care. The first 30 days after being discharged from the hospital are critical for a successful and speedy recovery. Seniors need to rest, get proper nutrition, and strictly follow discharge instructions in order to be able to regain their strength and heal quickly. After a serious illness, injury, or surgery, however, seniors are likely to have difficulty managing medications, going to doctor’s appointments, and performing daily tasks. Proper home care assistance is required to ensure their successful transition from hospital to home.

Here are some important tips for easing the hospital-to-home transition for your senior loved ones and ensuring their safety, comfort, and well-being after hospital discharge.

Be Aware of the Risk Factors

Preventing accidents and medical complications that could lead to rehospitalization starts with understanding the risk factors. For seniors transitioning home after a hospital stay, some common challenges include:

  • Mishandled medications: After hospitalization, seniors often experience changes or additions to their medication regimen. This can lead to confusion, causing them to miss doses or accidentally take too much. Such mistakes may worsen their health or result in serious side effects.
  • Injuries: After a hospital stay, seniors often face challenges such as reduced mobility, weakness, and disorientation. These issues can make navigating their homes difficult, increasing the risk of falls and injuries.
  • Overexertion: Recovering from an injury or serious illness can make even basic daily tasks exhausting for seniors. Physical exertion during this time may increase the risk of relapse or lead to new health complications, especially given the heightened vulnerability seniors face after a hospital stay.

Prior to Admittance

Planning ahead is crucial when an elderly loved one is preparing for a scheduled hospital stay. Start by gathering all necessary information about what to bring and any steps required before admission, such as completing medical tests.

Request a pre-admission packet from the hospital if one isn’t provided. This packet typically contains vital details, including visiting hours, payment options, hospital policies, directions for the day of admission, the scheduled admission time, and any required pre-admission tests. Being well-prepared ensures a smoother experience for both the patient and their caregivers.

Seniors and their loved ones can prepare for a hospital stay by assembling a personal hospital kit. This kit should include essential information to assist during treatment, such as insurance details, a list of prescriptions with names and dosages, contact information for doctors, emergency contacts, and any relevant test results or X-rays. Having these items on hand ensures a smoother, more efficient experience during medical care.

Communicate with Your Loved One’s Health Care Providers

Clear communication between hospital physicians and nurses, primary care doctors, and home caregivers is crucial for ensuring the safety and well-being of a senior after discharge from the hospital. To be able to help your elderly loved one recover, you need to be familiar with their illness, the treatment they are receiving, and the kind of care they are going to need at home.

Before your senior loved one is discharged from the hospital, you should ask their healthcare team the following questions:

  • What medications and specialized medical equipment will your loved one need?
  • What kind of at-home care procedures are recommended for your loved one?
  • Does your loved one need specialized home health care or only non-medical home care?
  • What are the specific risk factors for your loved one’s condition?
  • What steps can you take to mitigate the risks?
  • What signs or symptoms do you need to watch out for?
  • What should you do and who should you call in case of emergency?

You should also request the following information so you can better understand their discharge instructions and ensure that they get the proper post-surgical care:

  • Request explanations of terms and concepts you are unfamiliar with.
  • Ask for instructions in performing tasks such as changing wound dressings or administering injections to your elderly loved one at home.
  • Get a list of names and phone numbers of all health care providers your loved one will be seeing after being discharged.

It’s also a good idea to make a list of phone numbers of doctors and nurses from the hospital who are familiar with your loved one’s situation.

Manage Medications

Family caregivers and home care providers must familiarize themselves with the post-hospitalization medication plan. It’s essential to have an accurate and up-to-date medication list, understand the correct dosages, and know the proper timing for each medication. To ensure clarity and safety, consider asking the following questions about the prescribed medications:

  1. Ask for drug reconciliation: Your loved one may be prescribed a new medication, but they may be already unknowingly taking the same drug under a different name (in case they’re prescribed a brand name medication and were taking a generic version of the drug or a similar medicine in the same category before being admitted to the hospital). This may lead to unwanted side effects or even life-threatening situations. To avoid such problems, ask the hospital physician or nurse to check the list of new medications against the drugs your loved one was taking before the hospital stay and make sure the new medications are safe to take in combination with your loved one’s regular medicines.
  1. Ask for written instructions about your loved one’s medication regimen: Managing multiple medications can be challenging, especially when it comes to remembering which ones have specific side effects, need to be taken with food, or require precise timing. It’s essential to maintain an accurate medication list, understand the proper dosages, and know exactly when your senior loved one should take each medication to ensure their safety and well-being.
  2. Find out what is covered by insurance: If some of the drugs or medical devices your loved one is going to need after discharge are not covered by insurance, ask if they can be replaced with similar options that are covered.

Prepare the Home for Post-Hospitalization

To prepare for your loved one’s return from the hospital, consider ordering medical supplies that can ease their discomfort and support their recovery. A member of the hospital team can provide you with a list of recommended items, such as a commode, adult diapers, skin care products, a shower chair, or medical equipment like an oxygen supply. They can also guide you on where to source these essentials. If you’re working with a professional caregiver, check if the home health care service supplies these items. Additionally, consult your insurance provider to see if the costs for equipment and supplies are covered.

Make a Post-Hospital Care Plan for Your Elderly Loved One

When a senior returns home, unexpected situations may arise that require consultation with a healthcare professional. Be proactive by preparing a list of questions and gathering contact information for healthcare providers or nurses familiar with your loved one’s condition, whether from the hospital or a home care agency.

Stay alert for important signs or symptoms that might require immediate medical attention. For example, symptoms like fever, pain, or shortness of breath should be addressed without delay. Know who to call and which symptoms to report. Additionally, inquire about any specific restrictions, such as limits on heavy lifting, walking, climbing stairs, or driving, to ensure a safe and smooth recovery process.

Once you have all the necessary information and know your senior loved one’s specific needs, you can create an appropriate post discharge care plan and ensure successful transition from hospital to home care:

  • Make sure that family members or professional home caregivers will be available to assist your loved one 24/7 during the first 30 days after their return from the hospital.
  • Educate family members and caregivers about medication schedules, care procedures, and risks they should be aware of.
  • Obtain the medical equipment needed (such as hospital beds, bedside commodes, walkers, etc.) and have everything in place before your loved one is discharged from the hospital.
  • Assess your loved one’s home and make any necessary adjustments to increase at-home safety such as moving the bedroom from the second to the first floor, installing ramps to avoid traversing steps, and installing grab bars in the bathroom, near the toilet, and along kitchen walls and hallways, etc.

Transitional care will be easier and more effective when the home is properly prepared and adequate support is readily available.

Hire Professional Home Care

After a hospital stay, seniors are likely to be physically weak and mentally and emotionally overwhelmed. They will need compassionate and reliable support in order to recover and heal properly. While family members may want to provide the care their loved ones need, they might not always have the time, resources, or expertise to manage the demands of caregiving, especially when medical needs are involved. This is where professional home care becomes invaluable.

Professional home care services can play a vital role in recovery. They not only enhance the quality of life for senior patients but also ensure adherence to discharge instructions, reduce the risk of hospital readmission, and ease the burden on family caregivers.

Trained caregivers provide personalized assistance with tasks such as personal care, transportation to medical appointments, prescription pick-ups, grocery shopping, light housekeeping, meal preparation, medication reminders, and even support with medical equipment. Having an experienced professional by your side offers peace of mind for families while giving seniors the support they need to heal safely and comfortably at home.

Caregivers from a home care agency can help fill the gaps in hospital-to-home transitions and speed up recovery. They offer skillful, compassionate, and reliable care and have experience providing after surgery care for those who have been in situations similar to your loved ones. Discharge planners can work with the home care agency and help coordinate post hospital care before your loved one returns home.

Benefits of Professional Home Care After Discharge from the Hospital

When you work with Assisting Hands Home Care to care for your loved ones after they have been discharged from the hospital, you can expect our caregivers to provide the personal care and assistance they need so they can rest, regain their strength, and heal properly. Our care and support can also help your loved ones avoid returning to the hospital due to an injury, fall, or illness.

Our caregivers will help your loved ones with the following to ensure a smooth transition from hospital to home:

  • Medication management: Our caregivers play a vital role in supporting seniors by providing medication reminders and assisting with medical equipment. We help ensure that any updates to a senior’s medication regimen are properly implemented and followed, while also ensuring compliance with discharge instructions, such as staying in bed, walking periodically, or performing therapeutic exercises. Additionally, we monitor for signs of relapses, complications, anxiety, or depression, offering essential support to maintain the senior’s health and well-being.
  • Personal care: We will help your loved ones with personal care and grooming tasks, such as bathing, dressing, toileting, and mobility assistance that includes helping them move around the home, change positions in bed, and get in and out of their bed, recliner, and wheelchair.
  • Housekeeping and meal preparation: You can count on our caregivers to take care of light housekeeping tasks such as vacuuming, washing dishes, changing bedding, doing the laundry, and taking out the trash. We also manage meal preparation so your loved ones can get adequate rest.
  • Transportation: Our caregivers provide reliable, safe transportation to take your loved ones to follow up appointments and help with important errands like grocery shopping and prescription pickups.
  • Emotional care and support: Our caregivers bring empathy, companionship, and warmth to their roles to provide emotional support. We foster meaningful connections through conversations, games, and engaging activities.

Our home care plans are tailored to keep your loved ones safe and focused on their recovery after being discharged from the hospital:

  • We incorporate their discharge instructions into their personal care plans which helps avoid medication errors, prevent falls, and reduce the risk of accidents and other complications that could lead to readmission to the hospital.
  • We account for their dietary restrictions with our meal preparation and ensure they get the nutrition they need for a speedy recovery.
  • Taking care of light housekeeping tasks ensures that your loved ones recover in a clean and comfortable environment.
  • We ensure safe transportation to follow-up doctor appointments.
  • Our caregivers not only support your loved ones during their recovery but also offer comfort and reassurance to your entire family throughout the process. Through our compassionate care and companionship, we help keep spirits high which allows for a more positive recovery journey.

We can provide post hospitalization care for either short- or long-term periods, depending on your loved one’s condition and your family’s needs and preferences.

Hospital-to-Home Transitional Care from Assisting Hands Home Care

After Surgery Care at Home Schaumburg Illinois

If you or a loved one in Schaumburg, Hoffman Estates, Palatine, IL or surrounding areas, needs post-hospitalization care after returning home, you can trust Assisting Hands Home Care to provide exceptional care, personalized support. We work with you and your loved one’s healthcare providers to ensure that their discharge instructions are incorporated into our care plan and that we cover any other needs that can ease the hospital-to-home transition and allow for a speedy recovery.

Give us a call at (847) 448-0844 to set up a free, in-home consultation regarding our home health care services in the Schaumburg, IL area.

Tags: after surgery care, home care, transitional care
Previous post Aging-in-Place: How You Can Stay in Your Home Longer Next post How to Prepare Your Senior Loved Ones for Spring

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