Hospital to Home Care| A Guide For Hospital Discharge Planning

Hospital to Home Care

Hospital to Home Care


Seniors are temporarily hospitalized due to various reasons. Whether it’s a joint replacement or a quadruple bypass, recovering senior patients eventually need to return home. However, discharge instructions from hospital staff can get lost in the hustle and bustle. And, it further left family members and caregivers with anxiety and many questions about how to keep their loved ones safe at home during the recovery period.

The following guide is a collective list of typical hospital discharge recommendations as well as tips for setting up the home to make the transition easier for senior patients.

Transitional Care Strategies From Hospital to Home for Seniors

We understand that it could be sometimes quite challenging for family members or caregivers to get confused – what steps should they follow for transition from hospital to home care?

Let’s help you with this!

Make Sure the Patient Is Involved in Discharged Plans as Much as Possible

transition from hospital to home care

If a senior patient is coherent enough to participate in their own medical care and to voice their opinions regarding discharge, it’s the family members’ and caregivers’ responsibility to involve them. Recovering at a hospital is scary, and the unknown factors of discharging home with a change in routine and lifestyle are overwhelming.

To ease the process and to help seniors adhere to changes at home to promote their recovery, involve them in as many aspects of the discharge as you can.

See also – Live-in or 24-Hour In-Home Care Services: What You Need to Know

Talk to Hospital Staff About Discharging

Some hospital trips for seniors are unexpected due to falls, injuries, or illness. If this is the case, family members who are permitted to participate in the senior’s medical care process should start talking about discharge plans immediately.

Rather than wait until the patient’s anticipated last day, start the conversation early so that you can get the information you need – home health services, recommended equipment, medication schedule, etc.

If a senior patient is making an expected trip to the hospital for something like joint replacement surgery, family members and caregivers should talk about the discharge process with doctors and nurses before the surgery even takes place.

CDC has developed Covid-19 recommendations for Older adults and their caregivers to help them reduce the spread of COVID-19 at home or hospital.

Discuss Temporary Vs Long-term Changes to the Home

discharge from hospital to care home

Consult with doctors, nurses, and rehabilitation therapists about what changes at home will be necessary to aid in the senior’s recovery. Some patients return home and are expected to make a full recovery within a matter of weeks if they adhere to medical precautions.

Other seniors may be looking at long-term care changes because the matter of illness or injury is far too extensive than a full recovery and a return to normal life.

So, talk to hospital staff about what changes are necessary and what changes the individual patient can do without if recovery is short term (i.e. adaptive equipment, durable medical equipment, home renovations, medicine management schedules, home health services, etc.).

See also – How to Care for Dementia Patients at Home – Caregivers Guide

Research Home Health Services in Your Area

The doctors and nurses working with the patient in the hospital may suggest home care services if their recovery merits extra help. Oftentimes, hospital staff will recommend specific home health care agencies within the community to ease the process for patients and their families.

Thus, patients and their families start looking for home health care agencies recommended by hospital staff.  So, hop on the computer or your phone and research all home health agencies in your area. Ask about some of the following:

  • What specific services are provided by the agency (i.e. nursing, home health aides, social work, respiratory care, physical therapy, occupational therapy, etc.)
  • How often home health care staff will come to the home?
  • What insurance does each home health agency accept?
  • How long home health care staff will come to the home?
  • If the agency can start as soon as the senior discharges home.

We also recommend hiring an In-Home Caregiver Agency For Seniors, like Justin Villa Care, who provides assistance in every phase and can take care of your parents or seniors in every possible way.

Assess All Community Resources for Medical Equipment

transition of care from hospital to nursing home

During inpatient recovery, the senior patient may be visited by therapists including physical, occupational, and speech therapists. Depending on the post-operative condition, injury, or illness, each therapist will recommend specific medical devices to be used at home. Some examples include:

  • Hip kits (includes a reacher grabber, dressing stick, shoehorn, and long-handled sponge)
  • Toilet riser
  • Shower chair
  • Sock aid
  • Bedside commode
  • Walker
  • Wheelchair
  • Knee scooter
  • Crutches
  • Cane

Walkers, wheelchairs, and crutches are considered durable medical equipment and will often be covered by most insurance plans. Adaptive equipment such as hip kits, shower chairs, and toilet risers are not covered by insurance.

Some hospitals will refer family members to medical provider companies who can supply the patient with these items for home use. However, for families who are on a tighter budget, the same equipment can be located online and in stores across the U.S. Examples include, Walgreens, and Walmart.

So, talk to the senior patients’ therapy staff and ask about what equipment is necessary for safe recovery at home.

See also – What Factors to Consider While Paying Your In-Home Caregivers?

Give the Home a Good Run Through Before the Patient Discharges Home

Before the senior discharges home, walk through the home and see if all changes are accounted for and ready. This includes any necessary installations such as grab bars and wheelchair ramps as well as the removal of clutter such as throw rugs, garbage, objects blocking hallways and walkways, etc.

For families who are quite new to home modifications for seniors, consult with an occupational and/or physical therapist. Consider hiring a specialist to come and run a home assessment according to what the patient will need. Ramp and grab bar installations can be done by family members but can also be done by local hardware or home improvement stores.

Set Up Care Schedules Among Family Members, Caregivers, and Friends

Before the senior patient returns home, gather family members and caregivers who can devote their time to care for them during their recovery period.

Expect that home care staff won’t be at the home 24/7 for weeks on end, and that loved ones will have to step in and help the patient with the basics: dressing, toileting, showering, bathing, feeding, grocery shopping, Housekeeping & Laundry Services, financial management, medication management, and community access.

Therefore, it’s recommended to gather up an organized schedule of who can help at what specific times. Make sure that everyone is aware of the senior’s care plan for recovery. Depending on the medical condition, recovery will include rest, pain management, following ordered medical precautions, and carrying out prescribed physical activity.

Bottom Line

Family members and caregivers can proactively step in and ease the discharge process for seniors returning home from the hospital.

Make a list of caregivers & after discussing your requirements you can choose the best In-Home Caregiver agency for seniors. Consult with caregiver professionals frequently, don’t be afraid to ask too soon, get the home ready, educate yourself in the in-home recovery plan, and heavily involve the patient in the decision-making process.

If you have any questions regarding this, Justin Villa Care is here to assist you. Even we have highly qualified professionals who take care of your seniors throughout the transitioning process, from hospital to home.



Doha Isleta, L.V.N. has been the Client Care Manager at Justin Villa Care, LLC for over 10 years. She oversees each client case and makes sure that families are confident in the caregiver that they choose. She looks forward to helping you or your loved one live at home safely and independently.

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Justin Villa Care Implements Safety Measures to Protect Clients From COVID-19

Justin Villa Care is dedicated to implementing proactive measures during this difficult time to support our caregivers, clients and families. Here are some of the measures we are implementing to help your loved ones to stay home and stay safe.

Caregiver and Staff Education

Our caregivers and staff have received communication and training in:

  • Symptoms
  • Safety protocols
  • Travel reporting requirements
  • Proper handwashing techniques
  • Respiratory etiquette
  • Warning signs of illness
  • Infection control protocols, including effective cleaning and disinfecting of surfaces and hands Following CDC and local health authority guidance

Caregiver and Staff Monitoring

We will not place any caregiver with a client for a minimum of 14 days or until cleared by a medical provider if the caregiver has:

  • Been exposed to a facility where COVID- 19 is being treated
  • Traveled to a location on the CDC advisory list in the past two months
  • Started showing symptoms of the illness
  • We will not place any caregiver who has symptoms of illness on assignment or accept new clients who demonstrate symptoms that are highly consistent with the COVID-19 diagnosis or who have traveled to Level 1-3 areas in the most recent 14 days.

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