Transitioning Care from Hospital to Home
No one is 100% after a hospital stay. Relying on loved ones or rehab centers for aftercare helps — but it’s not always enough.
Almost 20% of patients end up back in the hospital within 30 days. Fortunately, the guidelines we outline below can help your loved one avoid a readmission.
Remember: For every checklist item, enlist others to help you. Chances are that you have many other responsibilities in your life. Teamwork works for everyone!
Discharge Instructions Checklist
Take good notes and speak up with questions. You may ask permission to record the discharge conversation on your phone, especially if you explain that you don’t want to bother them with a call in case you miss an important detail.
- Ask for a meeting with a discharge planner early in your loved one’s stay, ideally on Day 1.
- On the day of discharge, be sure to stay with your loved one during the entire discharge conversation. This is no time to get the car – a very common practice!
- Discuss the home environment for safety equipment that may be needed.
- Ask when the hospital stay records will be sent to your loved one’s main doctor.
- Confirm follow-up doctor appointments needed (when, with which doctors).
- Cover driving limitations (if any), and any other limits, like exercise.
- Record the medications administered the day of discharge, including the time and dose.
- Ask about signs or symptoms to watch for, when to get medical attention, and if there’s a hospital hotline.
- Find out if skilled care is needed. For example, speech therapy, physical therapy, occupational therapy, wound care.
- Get specifics on any diet and nutrition needs, including groceries to buy or remove from the home.
- Ask where to rent or buy any needed medical equipment or supplies. Tip: Many communities have lending programs through churches and senior centers.
- Ask if your loved one could benefit from electronic monitoring equipment, which reports info directly to the doctor.) Will hospital supply?
- Find out if follow-up tests are needed or if there are prescriptions to fill.
Common Problems and Pitfalls at Discharge
- Discharge instructions are often confusing, incomplete, and shared by hospital staff in a rush.
- Medication instructions can be incorrect, incomplete, or not well understood by the patient or their Care Partners.
- Appointments for follow-up testing or care with the patient’s doctors after discharge can fall through the cracks.
- Coordination for care and medical equipment needed following the hospital stay may be spotty or not provided at all.
- The patient may not be ready to leave (e.g., still medically fragile, the home is unsafe, the person is homeless, there is no one available to help the patient get prescriptions filled or assist with daily living needs).
- Infections picked up in the hospital may not show symptoms at discharge but will develop at home.
- The patient may not have enough help or the right kind of help coordinated to support their recovery.
- The patient’s home may not be safely set up to accommodate medical equipment or physical limitations.
- Social, welfare, and medical services may not be known, coordinated, or available.
Symptoms that Warrant Medical Help
- Depression, sadness, excessive sleeping, or inability to sleep
- Anything that seems unusual about emotions or mental alertness/thinking skills
- Any of these signs of infection, blood clots, heart or lung problems (most hospital infections show up after leaving): chills, extreme pain, fast heartbeat, shortness of breath, bulging neck veins, signs of fluid retention (puffiness, weight gain of 2+ pounds in 1-2 days), headache/migraine, diarrhea, nausea, fast breathing, coughing, swelling in legs or arms, body aches, cramps, no appetite, blood in urine, oozing/red sores, stitches, open breaks in skin, bumps, or rash.
Medication Record Spreadsheet
In the hospital, there are something like 13 steps involved in making sure a patient gets the correct medication — and mistakes still occur! Use our medication record spreadsheet to have a clear plan of what to take and when.
If home is in assisted living, memory support, long-term care or rehab, make doubly sure that:
- You completed the medication plan spreadsheet
- The spreadsheet is shared with everyone involved in their care
- The staff has several copies
- All nursing supervisors are aware of all medications taken the day of discharge and any changes to the medication regimen
- You call to follow up and confirm all details
Why Patients Often Overdose the First Night Home from the Hospital
- Patients are typically given a dose of medication before leaving the hospital
- The patient may take another dose too soon by mistake if they’re in the habit of taking pills before bed or their residential community administers pills on a schedule
- The second dose, taken too early, can send them right back to the hospital
Tips for Using The Medication Plan Spreadsheet
- Print the spreadsheet in Landscape mode on your printer
- Use standard printer paper (8.5″ x 11″)
Make as many copies as you need
Day-to-Day Responsibilities Plan
Create a plan for everyday tasks and determine who will pitch in to:
- Check in each day (in person or by video call) to monitor for positive signs of recovery or setbacks
- Schedule doctor appointments and follow-up tests
- Drive to doctor appointments and take notes
- Fill prescriptions
- Follow up on test results
- Arrange special support care and logistics (ex. wound care, home health, physical therapy)
- Find and purchase or rent medical equipment as needed
- Safety-proof the home
- Plan and coordinate meals
- Shop for groceries and household essentials
- Help with washing hair, showering, bathing, toothbrushing, dressing/undressing
- Help with walking or learning to use walking assists (cane, walker, wheelchair)
- Care for children, a spouse, pets, and other dependents
- Manage money and pay bills
- Facilitate conversations with employer as needed
- Clean the home, yard, walkways, perform seasonal upkeep
- Take out garbage
- Get the mail
- Do laundry
Potential Problems and Pitfalls after Leaving the Hospital
Daily living activities can be a challenge
Getting proper nutrition is a worry
Managing responsibilities the patient may have for others may be challenging and cause anxiety
Most of these items can be ordered from Amazon or Walgreens online. They should arrive promptly enough so that you won’t have to spend precious time running from store to store.
Preventing falls is a top priority. Here’s what to buy:
- Non-slip rubber mat for the tub or shower
- Grab-bars in the shower and next to the toilet (towel bars are not strong or secure enough to handle any weight)
- Shower sponge with long handle
- Shower chair
- Elevated toilet seat
- Hospital bed
- Hoyer lift (helps in/out of bed and chairs)
- Shoehorn with a long handle
- Sock aid to help put on socks
- Dry shampoo
- Reacher with long handle to pick up items from the floor or help with dressing
- Cane, crutches, walker, wheelchair
- Blood pressure monitor
- Pulse oximeter
- Bathroom scale
- Non-skid socks or a good-fitting pair of slippers
- Small blankets for chair, recliner, and sofa sitting
- Extra batteries for the TV remote
- Phone chargers
Safety-Proofing the Home
Try to imagine what it would be like to move around the home with less energy or physical limitations. Look for ways to make everyday life both convenient and safe for your loved one.
- Consider setting up one room to serve most needs, ideally on the main floor close to a bathroom or portable commode
- Equip with a bed, cell phone, TV, remote (with extra batteries), comfy chair, laptop, iPad, chargers, and any other creature comforts closeby
- Remove throw rugs in the house, as they’re a tripping hazard
- Consider an elecronic thermosatat that controls heat and air through an app
- Repair any uneven floors
- Place nightlights in halls, bathrooms, the kitchen, and any other rooms your loved one may use at night
- Remove any loose wires or extension cords where they trip or equipment could become entangled
Safety-Proofing the Bathroom
- Secure grab bars to the shower/tub wall and next to toilet either horizontally or vertically — not diagonally
- Consider a commode or raising the toilet seat height via an elevated seat
- Install non-slip suction mats or rubber silicone decals in the tub or shower floor to prevent falls.
- Be mindful of water on the floor and wipe it up immediately
- Make sure the towels are in easy reach of the shower or tub
- Make sure the shower curtain slides easily
- Clean up any messy drips from shampoo, soaps, or lotions
- Make sure a good hand soap is in easy reach of the sink faucet
Safety-Proofing the Kitchen
- Put glasses, plates, bowls, silverware and all food items in easy reach so that no tip-toes or bending is required
- Make sure the eating table and chair are sturdy and positioned so they don’t create a hazard
- Make sure entrances and pathways are wide enough to fit a wheelchair or walker if needed
- Keep the fridge and cabinets stocked with foods recommended for recovery and good health
- Remove food and drink items discouraged by doctors