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10 Tips for a Success Hospital to Home Transition

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Going from hospital to home is harder the older you are, according to the National Council on Aging.  It’s also more complicated than it used to be, since patients are sent home sooner, with greater expectations for self-care.

Family caregivers can use these tips to assist their older adult loved ones in the transition from hospital to home, which is a key first step in the return to independence.

  1. Understand the Discharge Planner’s role: Discharge planners coordinate a patient’s transition from the hospital to either a rehabilitation hospital, a.k.a. skilled nursing facility, or to home. Their recommendations are based information from the medical team and patient needs and wishes.  Since the discharge planner’s mission is to release the patient to a safe and successful recovery, providing patients and their caregivers with information and post-hospital care instruction is their primary task.
  2. Begin planning for the hospital to home transition as soon as possible (e.g. if your loved one will need a hospital bed, look into options, sources and insurance issues). The discharge planner will provide a list of needed medical equipment at the formal meeting.
  3. Attend the discharge planning meeting with your older adult loved one. Nebraska’s The Assisting Caregiver Transition Act allows a patient to designate a caregiver, for the caregiver to be present at the discharge planning meeting, and for medical task instructions and training, such wound care. (for more info, call AARP at 1-866-389-5651.
  4. If your loved one desires recovery at home, the discharge planner will want to know who will provide any needed care, such as family or professional caregivers. Honestly evaluate your loved one’s need for help with daily living tasks, (e.g. will your loved one be able to safely walk around the house alone, prepare meals, buy groceries, and attend doctor’s appointments?). The discharge planner should have a list of local providers.
  5. Give the medical team and discharge planner a list of all prescription and over-the-counter medications, and supplements taken prior to the hospital stay, with dosage amounts and times. The discharge planner may give new prescriptions and tell you to discontinue taking the old medications. It is not recommended for anyone to continue old medications without approval from the discharge planner or doctor.
  6. Write down all follow-up, therapy and doctor’s appointments, including contact information and reason for each
  7. Ask for a live, in-person demonstration of any special medical tasks you or other caregivers will be required to perform for your loved one, such as catheter care or giving injections.
  8. Understand when medication side effects, pain, or other post-hospital problems should result in a call to the doctor. Find out what you can do to reduce the risks and what are appropriate emergency actions.
  9. Request written discharge instructions, new medications, and a summary of your loved one’s health status. Bring this information to all follow-up appointments.
  10. Help your loved one participate in follow-up visits or calls and at follow-up doctor’s appointments. Sometimes an older adult’s pride blocks an honest flow of information. A brief note to the doctor prior to the appointment is a good way to support accurate information on pain, medication side-effects and other post-hospital problems.

Additional resources:

America’s Other Drug Problem, 9/11/16, Omaha World Herald

Family Caregiver Alliance


Home Care Assistance understands the “hospital to home” transition. Our Care Managers work with your medical team and you to help you recover as quickly and completely as possible.  We can help you create new routines so you’ll find yourself back to living, not back in the hospital. Call 402-261-5158 to speak to a Care Manager in Lincoln or 402-763-9140 in Omaha.  Our websites are helpful, too: HomeCareAssistance – Lincoln and HomeCareAssistance – Omaha.


Editor’s Note: This post was originally published in August 2014 and has been completely updated for accuracy and comprehensiveness.