After a Hospital Discharge: There’s No Place Like Home

If you are a family caregiver, it’s a relief at the end of a loved one’s hospital stay to hear

If you are a family caregiver, it’s a relief at the end of a loved one’s hospital stay to hear that it is finally time for them to return home. For you, this notice of impending discharge begins a period of transition that will determine whether they successfully resume life at home or are readmitted to the hospital. Fortunately, there are many positive things that can be done to increase the likelihood of success and decrease the chances of readmission. Your support and involvement during this period, especially the first 30 days after discharge, will be critical.

Preparing for Discharge

Before the discharge, make sure that:

• Your loved one has been involved in decisions about what takes place when they leave the hospital.
• A doctor or nurse has answered most of their (and your) important questions.
• They understand where they are going and what will happen after they arrive.
• You have the name and phone number of a person to contact if a problem arises during the transfer.
• You understand their medications, how to obtain them, and how to take them.
• You understand the potential side effects of their medications and whom to call if they occur. Double-check with the pharmacist when filling any new prescriptions.
• You understand what symptoms you need to watch for and whom to call if you observe them.
• You understand what they must do to keep their health problems from becoming worse.
• A family member or friend knows they are coming home, is available to provide care, and knows what they need.
• If they are going directly home, you have scheduled a follow-up appointment with their doctor and transportation to the appointment is available.
• The home is ready for them: medication, equipment, safety, and home modifications.

Responsibilities After Discharge

Medical appointments

• Make sure your loved one gets to every medical appointment – especially the first one after discharge.
• Make sure you write down and take any questions you or your loved one have to every medical appointment. Take notes at the appointment.
• For the first medical appointment after discharge, take all prescription and over the counter medications for reconciliation by the health care provider. Ensure that your loved one’s electronic medical record is updated to reflect them.

Medications

• Purchase and use a medication organizer; do not allow anyone to administer medications directly out of the bottle.
• Maintain an accurate list of all prescription and over the counter medications.
• Know how to contact the pharmacy that filled your loved one’s prescriptions for any medication questions.
• For every prescription and over the counter medication, know when it should be taken, how much to take, and how to take it.

Medical Information

• Keep a written record of your loved one’s health conditions, allergies, and medications.
• Keep a written record of the names and contact information for all treating health care professionals.
• Know what symptoms mean that your loved one’s condition is worsening and what to do if they occur.
• Understand which instructions in your loved one’s care plan are the most important and which are less urgent.

Daily Living Activities

Once your loved one is home, you may find that that even minimal activity and self-care are difficult for them because of changes in their body systems caused by bed rest in the hospital.  It’s not uncommon for an older adult to need more help than usual to get back into the swing of things. Some areas where they may need help during the transition period while they recover:

• Overnight standby for the first few nights at home.
• Reminders to take medications on time. This is critical; medication adherence issues can be responsible for readmissions and emergency room visits.
• If muscles have weakened, assistance with walking or transferring.
• Bathing assistance, especially if balance is returning slowly.
• Shopping and meal preparation.
• Laundry.

Family members or friends may be available to help in this area. The services of a licensed home care agency—even if only for 30 days—can relieve family members and provide trained, reliable support.

Resources

The University of Colorado School of Medicine’s Care Transitions Program is the basis of much of the information in this article. Their website (caretransitions.org) has many other useful resources and checklists for family caregivers supporting a loved one during and after a hospital discharge.