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By Sandi McCann
Reviewed April 2019, by Sara Russell, RN

It’s a startling fact: Twenty percent of the more than two million Medicare recipients who are sent home from the hospital, are readmitted within a month — often with more severe health complications, according to data published in the New England Journal of Medicine.

I’ve seen many families go through this. While it’s not uncommon for older adults to continue to their healing in a rehabilitation facility for a time after a hospital stay, they often return home before they are fully recovered. They aren’t quite ready or strong enough to manage the range of complicated care needs they have during recovery. This leaves families scrambling trying to manage multiple medications, wound care, mobility issues, and household chores, while their loved ones recover.

During this time, between hospital discharge and full recovery, older adults are more vulnerable and at higher risk for falls, medication mix-ups, infections, and other complications that can lead to rehospitalization and even death.

But with some solid planning and the support of a coordinated care team including professional caregivers, family caregivers, discharge planners, and home health nurses and other care specialists, you can minimize the dangers for your loved one and make an easier transition home, says Sara Russell, RN, a senior care specialist and a caregiver trainer and educator.

Caregiver Colorado

A smooth transition from hospital to home is essential, particularly for older adults with chronic conditions and complex care needs, according to a review in the American Journal of Nursing. It can ease stress, support healing, and recovery, and make everyone more comfortable.

That’s a big reason many families choose to work with our qualified caregivers as they move their loved one home from the hospital. Our caregivers are trained through the HomeCare 100 Advanced Caregiver Training Program in safe transfers, medication reminders, meal preparation, and other specific and complex care needs often required by patients after a hospital or rehab stay. We regularly drive and accompany our clients to medical appointments and can take detailed notes of the meeting for family members who cannot attend. This ensures that your loved makes their follow up visits which are key to recovery.

Could a professional caregiver be helpful to your loved one’s recovery? It’s something worth considering as part of the discharge planning process.

How to Plan for Hospital Discharge

Discharge planning might begin soon after your loved one is admitted to the hospital. Hospital planners will sit down with you, your loved one, and other family members to begin talking about the kind of care that you’ll need to provide at home as your family member continues to heal.

They’ll discuss things like follow-up care, home health care, which includes visits from a registered nurse or physical therapist to check on the patient, pain and wound care management strategies, and any home modifications that will be needed – such as bringing a hospital bed, installing grab bars, picking up area rugs – to support the senior.

At this point, many families decide to hire a professional caregiver to help them manage the long-list of complicated care requirements older adults often have when they first arrive home from the hospital or rehab facility. Our caregivers can provide short-term support while your family member recovers. Then, as he becomes stronger and more independent, we can reduce or eliminate those care hours altogether to accommodate his changing needs.

What else should you talk with discharge planners about? Ask about mobility support, so you know how to help your loved one transfer from bed to bathroom or chairs without risking injury to the both of you. And, medications, prescription schedules, potential side effects, follow-up appointments, and anything else that will influence your loved one’s recovery and health. The answers to these and other questions will help you put things in place ahead of time to make the transition home less stressful for everyone.

Questions to Ask Discharge Planners of Hospital Social Workers

  • When will my loved one be discharged home?
  • How will he be transported there?
  • Will he be able to get and out of the car on his own?
  • What problems should I expect?
  • Who do I call during the day and after hours if problems or concerns arise?
  • How will care and treatment continue after discharge?
  • Will home health providers –nurses, therapists, etc. — be coming to the house to provide care?
  • What medications will he be on and what are some side effects can we expect from the medication?
  • Will we need any medical equipment at home such as a walker, hospital bed, commode, oxygen tank?
  • How will I get that equipment and who will install it in the home?
  • Will my loved one need help bathing, dressing, eating, drinking, showering, toileting or with any other tasks of daily living?
  • Is there any special care or treatment I need to learn how to deliver such as providing wound care, insulin shots, or other care?

These are key questions I suggest families ask when meeting with doctors and hospital discharge planners. Feel free to print out our handy checklist of these and other questions to ask your discharge planner.

Transitioning Home

In most cases, some modifications of the home should be completed even before your loved one is released. And this is another way a professional caregiver can help. We work with families to help prepare the home for easy access and will set up the patient’s room to fit their preferences and abilities. We’ll make sure the things he most needs and enjoys – eyeglasses, hearing aids, phones, newspapers, television remotes — are in close proximity. Moving key objects closer is another risk reduction strategy used to prevent seniors from reaching and potentially falling out of the bed or chair.

Think of us as your safety net here to help your loved one avoid hospital readmission by making the transition home easier, safer, and a whole lot less stressful for you and your family.

When you do arrive home, you’re loved one will probably begin working with home health providers like nurses, therapists, and dieticians. Those visits will begin almost right away. You can also expect to have a number of follow up appointments at therapy and medical offices. You and your loved one will need to decide how he will get there and what kind of help you’ll need to move safely in and out of the car.

Our caregivers often transport clients to medical appointments and regularly work in collaboration with home health providers. A professional caregiver can serve as a bridge between family members, medical providers, therapists, and pharmacists, Russell says. And, also help you establish a supportive daily routine that aids recovery and eases stress and helps your loved one avoid complications.

Preparing for discharge? Call us today 720-204-6083. Our qualified caregivers can help you make a smooth transition.

Is Your Loved One Ready to Leave the Hospital?

There is a lot to do when a family member returns from the hospital and some pre-planning can make it easier to manage. Here are some things to consider ahead of time.

New Medications – Often, your loved one will come home with numerous, new medications. Make sure you know who will fill the medications and when and how they must be taken – with food, before meals? Twice a day or just once? What will the schedule involve?

Transfers and Safe Mobility – Your loved one is likely to be weak or have limited mobility, particularly after the fall, surgery, illness, stroke, or other condition that led to hospitalization. Helping him to move from the bed, bathroom, chair or vehicle can be difficult and frightening for both of you. Make sure you have walkers and other devices in place if needed and know how to help your loved one move safely.

Bathing and Personal Hygiene Care – Personal care and hygiene is an important and often difficult part of recovery. Good hygiene helps minimize the risk of illness and health complications, and people feel more comfortable and refreshed when they are cleaned and cared for.  Can you provide consistent hygiene and personal care in a way that is efficient and preserves your loved one’s dignity?

Exercise, Activity, and Companionship – Appropriate strength-building activity, mental engagement, and physical therapy exercises are three ways seniors can regain their strength and heal faster. How will these things be provided?

Support – Who can help you? A neighbor, another family member, professional caregiver. Nobody can deliver quality care alone and returning from the hospital is stressful. Make sure you have some support in place to help and also give you time to keep up with other household responsibilities like chores and bill paying.


Sandi McCann is the Founder and President of HomeCare of the Rockies, a provider of non-medical caregivers to older adults throughout Boulder County. McCann is also the creator of the HomeCare 100 Professional Caregiver Training Program, an innovative educational strategy that provides advanced training to non-medical caregivers.

Sara Russell, RN, is a registered nurse, senior care specialist, and caregiver educator.

HomeCare of the Rockies caregivers receive 100 hours of classroom and hands-training that can help your loved manage all these care needs and more. We are here to help the people you care about heal safely and comfortably at home. Call us, 720-204-6083, we can help make this stressful time easier.

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