Transitioning from Hospital to Home

Author: Tami Rogers

| Published on: January,18 | Viewed: 2292 times

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When an elderly person ends up in the hospital, it can be a very stressful time for a caregiver or family member. In addition to worrying about the health and welfare of your loved one, you need to be consulting with doctors, insurance companies, additional family members and perhaps advanced directives. It’s a lot to think about.

But an important thing you also need to consider is coming up with a plan once your loved one is ready to go home. Many caregivers who don’t think ahead find themselves struggling to put something in place quickly when the doctor says “She’s ready to go home.” With a little forethought and the right resources in place, you can make the transition go a lot smoother.

Discharge planning

When you consult with the hospital’s discharge staff, be sure and make them familiar with all aspects of your loved one’s medical history and care, including medications they take and any other physical or mental capabilities that could impact their recovery at home.

You also need to discuss any physical, financial or time-related obstacles that could keep you from caring for your loved one once they’re home. The hospital staff should have a list of resources that  can help, including in-home care, a rehabilitation facility or a nursing home if needed.

They can also help you with financial concerns by bringing in a social worker on staff. A social worker can go over any benefits or entitlements your loved one qualifies for and help put them in place before you leave the hospital.

Unfortunately, not all hospitals rate equally when it comes to the quality of their discharge care. There is a surprising lack of consistency in the process across the health care system.

In fact, studies have shown that as many as 40% of patients over 65 had medication errors after leaving the hospital and 18% of Medicare patients were readmitted to the hospital within 30 days.

Come prepared

There are certain aspects of a good discharge plan that can help ensure your loved one gets the best care possible once they return home.

In the best circumstances, particularly if your loved one has complicated needs, the hospital has a team approach to working on his or her discharge plan. That can include a nurse, social worker and/or caseworker.

Here are some things any good discharge plan should include:

  • Evaluation of the patient by qualified personnel

  • Discussion with the patient or his representative

  • Planning for homecoming or transfer to another care facility

  • Determining if caregiver training or other support is needed

  • Referrals to home care agency and/or appropriate support organizations in the community

  • Arranging for follow-up appointments or tests.

Keep in mind your loved one should have a follow-up appointment with their doctor before you leave the hospital.

Paying for care after discharge

Insurance, including Medicare, does not pay for all services once a patient has been discharged. However, if something is determined to be “medically necessary,” your loved one may be eligible for coverage for certain skilled nursing or equipment. Check with the hospital, your loved one’s insurer or Medicare to see what may or may not be covered. Keep detailed notes about your conversations as well.

For more information including a downloadable hospital care discharge guide, check out this helpful website. For more information on in-home health care for your loved one’s transition, check out this article on Seniorly.

Trust Seniorly for the most up-to-date information on retirement communities, independent living and elder care. Visit us online or call (415) 570-4370 to schedule a free consultation with our gerontologist! 


About Tami Rogers

Tami Rogers is a mom, award winning writer, passionate chef, blogger and frequent contributor to Seniorly and other sites dedicated to seniors and aging well. She also writes for parenting magazines and websites focused on the emotional well being of teens.


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