Last updateWed, 18 Oct 2017 10am

Senior Lifestyles

Smoothing the transition: Moving from hospital to home

As we reach the senior years, an increasing amount of medical care is delivered in hospitals and rehabilitation centers rather than physicians’ offices. For patients in their 80s and 90s, it’s not uncommon to be admitted and readmitted to the hospital multiple times in a year. Indeed, more than 30 percent of Medicare patients will return to the hospital within 90 days of discharge for a complication related to their original condition.

Each visit to the hospital takes a toll on an older adult patient. But it also takes an emotional toll on the concerned loved ones who help navigate the complicated process of hospitalization on their behalf. Today’s hospitals are complex, fast-moving places. It’s easy to get lost in the shuffle without a family member or friend watching after the details.

Managing the in-hospital care plan and treatment upon admission is a subject that merits its own article. I usually speak to families at the point where treatments have been initiated and discharge is within view. That date often comes sooner than expected. So I advise families that a little knowledge of the process and planning goes a long way to reduce the already stressful process. Most importantly, it can help prevent an unnecessary return to the hospital.

Knowing the players

The days of interacting with your primary physician on care in the hospital are long gone. Administrators largely manage the processes, so it’s important to get to know their various roles. They include the discharge planner, social worker, hospitalist and nurse case manager, as well as physical, occupational and speech therapists. You will likely meet these various professionals in the course of treatment, but it’s the discharge planner that will become the main liaison for the transition to home.

Preparing for discharge

Discharge day arrives quickly. Patients and family usually receive 24-48 hours’ notice, but the actual date and time often changes. The sooner you initiate discussions about discharge, the better. Start by:

• Assembling a support team of family and friends.

• Identifying key personnel and their roles.

• Understanding discharge timing and windows.

• Understanding discharge criteria.

• Determining whether transition will be to home or a rehabilitation facility.

• Setting up pre-discharge training.

• Setting up pre-discharge home safety assessment.

• Determining the necessary home medical equipment.

Discharge day and transition home

The actual transition home can be the most stressful part of the process. The first 48-72 hours after arriving home are often the most challenging. When preparing for the trip home, think about:

• Arranging transportation home.

• Filling new prescriptions and medications.

• Understanding new nutrition guidelines.

• Understanding and preparing for sleep patterns that may be off.

• Putting proper care coverage in place once home.

• Coordinating referral services like home health-care nurses.

• Setting up follow-up medical care and appointments.

Staying at home

With a little planning and teamwork, you can reduce the chances of returning to the hospital by putting the support structure in place before you arrive home. These activities include:

• Putting emotional and social support in place through family and friends.

• Maintaining day-to-day care coverage through family, friends or outside help.

• Setting up and managing ongoing medications.

• Implementing recommended home safety measures.

• Reinforcing physical exercise and rehabilitation for recovery.

• Setting up proper diet, nutrition and hydration.

• Putting a longer-term care plan in place for the new realities of life post-hospitalization.

Upon returning home from the hospital as an older adult, there are often new realities that prevent complete independence. It’s common for patients and loved ones to differ on the amount of assistance needed and, indeed, welcomed. But if preventing a return trip to the hospital is a primary goal, establishing the necessary foundation of care and social support from the start is crucial.

To download the free nine-page guide “Making the Transition from Hospital to Home,” visit www.homecare-california.com/hospital_to_home.

Greg Hartwell is managing director and CEO of Homecare California, a Los Altos-based in-home care-giving agency. He is a frequent guest speaker on elder-care issues. For more information, call 324-2600, email This email address is being protected from spambots. You need JavaScript enabled to view it. or visit www.homecarecal.com.

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