Hospital-to-home transitional care: What you need to know

June 20, 2022

Healthy Aging Wellness
Shot of a senior man using a walker with his wife and nurse

You’re in the hospital or rehab facility. Maybe you’re recovering from surgery or treatment for an illness. And now, you’re eager to go home.

Before you leave, you can expect a case manager, social worker or other professional to stop by your room for an important conversation – your discharge planning.

“With discharge planning, we consider your doctor’s care recommendations, your overall condition, and what you will need to live well and make a safe, smooth move from hospital to home care,” explains Teresa McConaughy, M.D. “People who are chronically or seriously ill may need different types of care than someone who had a minor procedure.”  

Your input – and your family’s – is vital. To make a successful transition from hospital to home, consider these seven questions:  

1. Will you need a full- or part-time caregiver?  

The decision to bring a caregiver into your home is a very personal one. Sometimes, family members or close friends assume the role of caregiver. Or you might consider hiring a nurse aide from a local service. 

While you’re recuperating, this person would help you with:

  • Skilled nursing care
  • Personal care and bathing
  • Administration of medicines 
  • Meal prep 

If you can’t find someone to stay with you and perform these duties during the day, consider whether an adult day care facility is an option for you.  

Meanwhile, you might also need help with other daily tasks and errands, such as:

  • Cleaning  
  • Laundry
  • Grocery shopping
  • Financial matters 
  • Yardwork

2. Will you need special equipment at home?  

Depending on your condition and your abilities, you may need: 

  • A hospital bed 
  • A bedside toilet 
  • Oxygen equipment 
  • Adult pullups 
  • Wipes 
  • Disposable gloves
  • Skincare products 

Ask the care coordinator at your hospital how to order these items and how to check whether insurance will pay for them. 

3. How will you move around your home – and around town?

The answer might be: a walker, wheelchair, scooter or crutches. Be aware that sometimes Medicare covers the cost of these items. Your physical therapist or hospital social worker can help you find out. 

If you will need someone to drive you to doctor appointments or run errands, some agencies offer volunteer escort services. Or, maybe you could arrange for a relative, friend or neighbor to take you. 

4. What medications will you need to take? And how often? 

Before you go home, you should receive an updated list, with written instructions about how and when to take your medicines. To help you remember, you can use a special pill box organizer that allows you or a caregiver to divvy out your pills for each day and night of the week. Make a list, and check it off as you take it.  

5. Is your home safe and accessible?

Consider the need for new safety features, such as:  

  • A ramp leading to your front door 
  • Safety grab bars around the toilet, tub or shower  
  • A shower chair or walk-in shower 

Also, look around your home for potential tripping hazards.

“To help prevent falls and accidents, get rid of throw rugs, magazine racks, brooms and buckets. And be aware of height differences between carpet and other types of flooring so that you don’t stumble,” explains Dr. McConaughy. “You can also install extra lighting in doorways, stairways, hallways and bedrooms.” 

6. Will you need visits from a home health nurse or therapist? 

Even if you have a family caregiver or friend to look after you, your doctor may recommend periodic visits from a:  

  • Home health nurse – to check your blood pressure and other vital signs  
  • Physical therapist – to help you rebuild strength  
  • Occupation therapist – to help you bathe, dress, and perform other daily activities
  • Speech therapist – to work with you on language skills or to check your ability to swallow safely

7. How will you keep up your nutrition? 

After a surgery or illness, some people find it difficult to stick to a nutritious diet. They might not feel like cooking or going to the grocery. Or, they might not feel hungry. Be sure to call your doctor if you experience these warning signs of poor nutrition:  

  • Unusual weight loss 
  • Trouble chewing or swallowing
  • Change in appetite

To help ensure you get the proper nutrition, consider asking family members or friends to drop off occasional meals or groceries. Seek out local agencies that offer low-cost meal delivery services for senior citizens. Ask about the SNAP program (Supplemental Nutrition Assistance Program), which helps families with low incomes buy more nutritious foods. Your doctor can also recommend liquid nutritional supplements and multivitamins. 

To learn more about living well and making a smooth transition from hospital to home, contact our professional senior care navigators at Riverside Health System.

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