Creating a plan for your loved one to transition back home from the hospital or rehabilitation center is the key to a successful outcome. Planning should begin on the day of admission to the hospital. Many people are unaware that while a loved one may appear quite ill or lack their usual mobility or faculties, they may be discharged quickly and unexpectedly once their doctor determines that they are medically stable or have met their treatment goals.


The best time to be released from the hospital is the morning, so ask your discharge planner for an early discharge. This will allow you time to obtain medications from the pharmacy and purchase needed supplies, groceries, or equipment. It will also give you a cushion of time to manage unexpected problems, such as checking on equipment that wasn’t delivered on time, obtaining clarification of orders for new medications, or making alternative plans if a scheduled caregiver does not show up.


Most people benefit from having 24-hour supervision (by family members or a caregiver agency) for at least the first three days back at home. Caregivers should monitor the following important issues: compliance with medications; preparing nutritious meals; assisting with mobility or personal care; transportation to follow-up physician appointments; seeing that skilled home health is provided as ordered; and maintaining the basic household upkeep and cleanliness.


Failure to plan appropriately may lead to the onset of new problems that may cause your loved one to be readmitted.


The most common issues that result in someone being readmitted stem from a failure to take new medications as prescribed or confusing new and old medication regimens; poor nutritional intake or lack of adequate fluids; and falls due to medication issues, trying to be independent beyond one’s ability, or lack of appropriate nutrition and hydration.


Consult with your hospital discharge planner or social worker or hire an independent geriatric care manager to assist you with planning. For example, if it is anticipated that your loved one will benefit from transitioning to a rehabilitation center prior to discharge, then you may obtain a list of skilled nursing facilities to visit and make a selection that you feel will best fit your needs.


Additionally, if your loved one is transitioning directly home from the hospital or rehabilitation center, consult with the discharge planner to obtain orders for skilled home health care. If your loved one does not have family available to assist, or if their care needs are greater, then consider hiring a home care agency to help.


Being released from the hospital is only a joyous event if you are able to create a workable plan and keep your loved one at home.

Machelle Thompson, PT, CMC, President, and Geriatric Care Manager, Keen Home Care, has been a senior advocate for more than 25 years, working as a Physical Therapist, Nursing Home Administrator, and Geriatric Care Manager. Her company, Keen Home Care, provides in-home caregiver services and consulting for seniors and their families (call 562-438-5336 for more information). A long-term Long Beach resident, Machelle serves on the board of directors for Community Hospital Long Beach Foundation, Long Beach Business Executives Association, Estate Planning and Trust Council of Long Beach, and Arts and Services for the Disabled.