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Successfully Transitioning Senior Loved Ones Home from the Hospital

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When older adults return home from the hospital, it’s the little things that often get overlooked. They’re sent home with detailed discharge plans containing important information and instructions to review with family members. However, families may not anticipate the additional tasks required to create a smooth transition home for their aging loved one. Professionals in the aging space can help older adults and their families best prepare for the transition and by providing support and resources.

When considering the assistance an older adult may need after being hospitalized, there are four key activity areas that may require family caregivers to assume more responsibility, time and effort than normal day-to-day activities. Many of these activities may also be delegated to home care’s trained professionals or home health care services.

Health-related Tasks

  • Review discharge plan or care plan
  • Change dressings
  • Monitor vital signs
  • Operate or adjust medical equipment
  • Assist with personal hygiene
  • Arrange for follow-up care
  • Maintain a schedule of health care visits and appointments

Medication Management

  • Order and pick up prescriptions and refills
  • Understand all medication labels, instructions and expiration dates
  • Administer the correct medication at the right time
  • Monitor for side effects
  • Store medications properly and safely
  • Maintain medication schedule
  • Dispose of medications
  • Use a medication tracking system to record all medications

Household Management

  • Ensure safe environment by completing frequent home safety checks
  • Check fridge for outdated and spoiled foods before discharge is complete
  • Prepare special meals to meet new dietary restrictions, such as low sodium or liquid-only diets. This guide can help.
  • Shop for what is needed upon returning home, including special foods and new supplies
  • Manage communication and scheduling with visiting health care and home care professionals
  • Arrange for medical supplies and equipment deliveries

Family Communications

  • Prepare and maintain emergency and medical contact lists
  • Communicate frequently with family members and healthcare team
  • Pay medical and other bills
  • Assist with mail
  • Provide instructions and training to other family members and friends
  • Assemble and store important documents like an advance directive or will (living or standard) in a senior emergency kit

Family members are often overcome by the wide range of caregiving responsibilities. This may be due to the necessary time commitment, a lack of confidence in their caregiving skills or the inability to provide for these needs. This potentially mind-boggling responsibility could, unfortunately, result in missed follow-up appointments, medication mismanagement and hospital readmissions.

Readmissions are not only distressing for older adults and their families, they are also an undesirable outcome for the health system. According to data from the Medicare Payment Advisory Commission, nearly one in five seniors discharged from the hospital will be readmitted within the first 30 days due to preventable factors. Support at home can help identify those preventable factors and reduce the risk for readmissions.

What Type of Support is Available at Home?

In addition to the vital support and care provided by family members, there are two common types of support that are often recommended for an older adult returning home from the hospital: home health care and professional home care.

Home Health Care
Home health care is a service that focuses primarily on medical tasks provided by certified or licensed healthcare professionals. Care is typically provided for about one hour per day. Home health care may be covered by Medicare for a short period of time after a hospital stay. Examples of home health care services include:

  • Post-Op Rehab
  • Skilled Assessments
  • Therapy: Occupational, Physical, Speech
  • Wound Care
  • Mobility Training
  • Pain Management
  • IV Therapy/Injections

Professional Home Care
Professional home care, can support an older adult alongside home health care. Home care creates a customized care plan to help with discharge plan compliance. The services can be tailored to assist a few hours a week up to 24/7 during the transitional period and beyond. Home care provides a range of services from personal care, activities of daily living (ADLs), medication management, home maintenance, transportation and Alzheimer’s or dementia care. No matter if the individual is transitioning home to a residential home or to a care community, the flexibility of home care accommodates services in a variety of settings.

The overall goal of home care during a transition from the hospital is to increase positive outcomes for aging loved ones and their families. A recent study conducted by Home Instead, Inc., franchisor of the Home Instead® network, found many benefits of home care services, including:

  • Increased amount of care
  • Fewer visits to the doctor
  • Improved quality of life for both seniors and their family caregivers
  • Positive economic impact, including reduced medical care costs
  • Shortened hospital stays
  • Reduced hospital admissions
  • Extending care along the continuum

Steps Families Can Take
There are important steps families can take to help smoothly transition their loved home from the hospital.

  • Before leaving the hospital, ask clarifying questions to ensure the discharge plan is understood.
  • Prepare the home for their loved one’s return.
  • At the time of discharge, complete this downloadable discharge checklist.
  • Once home, family members and professional caregivers can help monitor their loved one looking for any changes in condition. Report those changes to the correct medical professionals.

To learn more about the transition from hospital to home, watch this webinar. Professionals can earn a free Continuing Education (CE) credit*. For more resources related to readmission reduction and transitional care services, visit To learn more about professional home care services and to find a local home care provider visit

*CE credits are only available for 60 days following the live webinar event.

Last revised: April 8, 2019

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