Hospital to Home Transitions: 8 Steps for Patient Success

Hospital to Home Transitions

Hospital to Home Transitions: 8 Steps for Patient Success

Learn how to ensure success with transitional care strategies after post-hospital discharges for patients and seniors.


You or a loved one has a fall, has a stroke, suffers an illness or another health event and ends up hospitalized. Before you know it, the hospital nurse or social worker starts discussing the discharge process. Now, you need to begin to make arrangements for these transitions of care. 

Transitions of care can happen in many ways. They can happen from an inpatient to outpatient setting, or from one outpatient provider to another. The patient can go from one inpatient setting to another, and finally from the inpatient setting back home.

These transitions create scenarios in which the care of a senior patient is handed off to a new set of medical providers and/or to home-based family caregivers. This happens in the case where the patient is being discharged to their home after a hospitalization occurs.

An effective transition will help to reduce the likelihood of inappropriate care or potential medical complications as they return home. The content and understanding of the written discharge instructions provided to families or caregivers is a critical element for a successful transition back into their own home.

senior patient discharge planning

What is discharge planning?

Hospital discharge planning is the process used to decide what a patient needs for a smooth and successful transition from one level of care (like a hospital) to another (like a nursing home or to the patient’s home setting). There are different options when it comes to deciding where an individual will be discharged to. Some options include the home, a long-term or rehabilitative healthcare facility, or another permanent residence. Medical professionals can help create a discharge plan. However, the physician themself is the only one that can provide an authorization for discharge.

Planning for the Hospital Discharge of the senior patient

Whether the hospital stay for you or your loved one is a planned or unplanned event, the hospitalization and pending discharge can be stressful. You can make it a little easier if you know what to expect and prepare for success.

Hospitals generally screen most admitted patients within 48 hours of entering the hospital. This is to determine a discharge plan is needed. A discharge plan should be made for patients who are at high risk of complications or susceptible to a future readmission.  If the hospital does not require it, it may be beneficial to work with a doctor or discharge planner to create one. A discharge plan supports an effortless recovery and can help to prevent an unnecessary hospital readmission.

Consider these eight key steps to assist you in planning a safe and smooth transition from hospital to home or to a rehabilitation center:

Step 1

Consult with the hospital discharge planner. The hospital discharge planners exist to aid in the discharge process. The hospital is responsible to ensure that the discharge is a safe one by considering your individual needs and support. 

Step 2

hospital to home transitions

Talk about the benefits of discharge to a skilled nursing facility versus the home setting. These considerations and any other issues specific to your situation with the hospital discharge planner are both important to determining what the right course of action is for you.

Skilled nursing homes offer a higher level of care and therapy than is normally the case at home. A nursing facility can provide skilled nursing care services, a hospital bed, therapy services, assistive equipment and personal care support, plus meals and activities. 

These same services, including home health care (skilled nursing care, occupational, physical, or speech therapy) as well as other services and durable medical equipment or out-patient therapy, can also make a home discharge possible. Nevertheless, you additionally may need to make arrangements for a caregiver or family member to assist with activities of daily living (like bathing, dressing, and running errands.

Step 3

Write down medication instructions and confirm them. Up to 40 percent of patients over the age of 65 have had medication errors after leaving the hospital. For many people, understanding the basics of prescribed medications what they entail can be difficult. Get concise and clear written instructions from the hospital staff. Also, confirm them with the doctor. For example, some medications need to be taken at specified times of the day, but not all meds are taken the same way. Ask any questions you have as needed. Medication errors or instructions on taking them is one of the biggest challenges in hospital to home patient discharges. Don’t feel discouraged or embarrassed if you or a loved one don’t understand the instructions. It’s more difficult than you think to navigate, and there’s too much at stake to not clarify.

Managing medications at home can be tough. Therefore, you may want to purchase a pill organizer or  consider pharmacy services like PillPack, which packages and delivers medications with clear instructions for you.

Step 4

hospital to home discharge planning

Champion for a safe discharge. Hospital discharge planners are under pressure to make a successful discharge for a large number of patients. As a result, it is vital to be an advocate for yourself or your family member. This will help make sure that the proper arrangements for a safe discharge are in place. Additionally, it ensures that the transition plan is one that works best for you or your family. 

Step 5

Request that your discharge planner or your doctor make preparations for the services you require. This includes transfers or transportation to your home or to a nursing home setting, along with durable medical equipment for the return home (if applicable). The hospital won’t arrange for personal care services in most cases. They will usually have a list of approved or recommended home care agencies for your review though. These discharge planners may narrow the choice to three options. You can also request the agency or nursing home setting that you prefer to work with also. A geriatric care manager is another key individual that may coordinate, arrange, and oversee care. This can be helpful if there is no available support or family in the vicinity. The assigned discharge planner may also provide a recommended list of care managers.

Step 6

Evaluate home care providers before being discharged. When you or a loved one requires care at home, it’s vital to hire someone you can trust in and are confident will provide excellent care for a loved one. You may be handed a list of agencies at the hospital, but finding a good fit is crucial to your peace of mind and the health of your senior loved one. Home care agencies will be in the home and spend a substantial amount of time with you and your loved one. As a result, it’s not a decision to take lightly. Evaluate your options, speak to family members and friends, and ask as many questions as you need to feel comfortable making a hiring decision.

Step 7

prepare home for successful patient discharges

Prepare the home for success. Before the senior patient gets discharged, it’s important that everything in the home will enhance your loved one’s safety and comfort. This may include moving furniture so that your senior family member can to move around the home. Make sure that the residence is adequately cleaned so that the space promotes health. If necessary, arrange to have a hospital bed or large medical equipment delivered to the home and setup before the patient discharge. Display emergency numbers and health provider information in a visible place (such as right on the fridge).

Step 8

Make your decision, confirm the arrangements made, and collect all pertinent contact information so that you can follow up after your discharge. Review your post-hospital health care discharge instructions in detail. If you don’t understand or are unclear about any of the instructions ensure that you clarify them with your doctor or the discharge planner. Confirm that any medications prescribed and ordered will be available when you need them.

Finding the right senior patient support

senior discharges from the hospital

The first 72 hours home are critical for post-hospitalization patients. Patients are fatigued and family members are often confused and helpless. In addition to a comprehensive discharge plan, a caregiver can help manage the transition home and help you on the path towards a successful recovery.

A leading cause  of hospital readmissions is due to a lack of sufficient individual support after a hospital discharge. To help make the transition back home a successful one, Chosen Family Home Care is committed to helping seniors and their loved ones receive beneficial post-hospitalization care through our care transitions program. This program follows a comprehensive set of steps and resources for families managing the sometimes difficult transition home after a hospitalization. Contact Chosen Family Home Care to get a free consultation or partner in successful discharge planning today.


Read more about ways to improve senior health and prevent hospital admissions in the first place by considering several other resources:

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