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From Hospital to Home Care: The Discharge Process

19 January 2017
  Home Care Assistance Prescott | Partner Content

One of the Leading Causes of Hospital Readmission or Slow Post-Hospitalization Recovery Is the Lack of Proper Support Following a Hospital Discharge

After being discharged from the hospital, 35% of seniors are readmitted after only 90 days. For seniors, hospital readmission is usually a result of not following doctor’s recommendations, medication instructions or a poor recovery environment. While many patients want to immediately return home following a hospital discharge, this is not always a viable option. As a stay in the hospital draws to a close, the patient will typically be presented with two options for the recovery process.


After a patient has undergone a procedure in the hospital, such as a hip replacement, or been admitted for an unexpected medical event, such as a stroke, a care manager will typically recommend 30 days of rehabilitation at a facility. Ultimately, the patient and the patient’s loved ones can decide if this is a good option.

A stay in a rehabilitation center is typically covered by Medicare. These benefits will frequently cover three to four hours per day of active rehabilitation — whether that is physical therapy, occupational therapy, or speech therapy. Additionally, each rehab facility is overseen by a Registered Nurse and every patient is assisted by Certified Nursing Assistants. For skilled nursing facilities, the Medicare benefit pays for several weeks of care so long as the patient demonstrates progress in therapy, or the condition is unstable enough to require around-the-clock skilled nursing.


Any extended stay in a medical facility can increase the risk of infection or illness, simply due to the proximity to patients recovering from illness. Likewise, for some people, further stay in a hospital setting can lead to depression or a feeling of being institutionalized. By nature, facility care is very structured and outside of pre-set therapy times, patients are often bedbound. In addition, care staff are often spread across many patients, limiting the amount of individual attention. In fact, for many procedures, including hip replacement, a carefully planned discharge to the home is a more effective recovery solution. Further, though Medicare typically covers some level of post-hospitalization rehabilitation, coverage is not guaranteed and subject to regular evaluations of the patient’s condition.


Patients who prefer the comfort of more familiar surroundings also have the option of recovering and undergoing the rehabilitation process in their home.


Working with a personal caregiver provides the individual customized attention ranging from a few hours a day to around-the-clock care 24 hours a day. Likewise, visiting therapists can cater to the specific recovery needs of a client at home. For example, to practice walking up and down the stairs, a therapist can utilize the exact staircase the patient will eventually need to climb. This level of customization is not available in a rehab facility. In addition, the patient benefits psychologically from the comfort of home and has a smoother transition back to a familiar routine and lifestyle. Further, patients recovering at home can benefit from full-time, 24-hour services from a caregiver; the level of care is far more personalized than at a nursing facility and families enjoy peace of mind knowing a trained professional is always at home. For most adults transitioning out of the hospital setting, home care is the solution that offers the greatest security and happiness for the client and the most peace of mind to his or her family.


While short-term home health agency costs may be covered by Medicare, private home care is typically an out of pocket expense though the caregiver can provide dedicated one-on-one support at a level beyond the services of a rehabilitation facility. Caregivers provide their clients full-time support, addressing a range of needs from meal preparation, transportation and housekeeping to more complex needs associated with chronic conditions such as Alzheimer’s, dementia or Parkinson’s . Home care can be an integral part of patient outcomes and quality of life following a hospitalization. Consider speaking with a Home Care Assistance care manager about the Transition Home™ package and a personalized care plan for your specific situation.


The Patient 

The most important person in the discharge planning process is the patient. The care team will typically respect the patient‘s preferences during the discharge process. Recent studies have demonstrated that recovery at home is comparable to, and in some cases more favorable than, recovery at a facility. However, every individual has his or her own preferences when it comes to discharge. This is why it is critical to establish open lines of communication as early as possible during the hospitalization. Clear communication allows the patient to voice personal desires and concerns and allows the discharge team and family members to share their thoughts and recommendations.

The Patient‘s Family Members and Caregivers 

Family members and caregivers are a vital part of the discharge planning process because they are the ones who will help manage the patient‘s care in the home or post-hospitalization facility. They can provide valuable input to the discharge team that the patient may not have fully considered. For example, a patient may be steadfast in the desire to return home, but the patient‘s family may alert hospital staff that there is no one in the home strong enough to transfer the patient, who cannot yet walk independently. It often falls to the family to ensure that the best possible decisions are made for a successful recovery and optimal wellbeing.

The Discharge Planner

The discharge planner, usually a nurse or a social worker, coordinates a patient‘s discharge from the hospital and post-hospitalization care strategy. The discharge planner wears several hats. She has to consider cost effectiveness for the hospital while also considering the family‘s wishes and the wellbeing of the patient. To balance these priorities the discharge planner must maintain good relationships with post-hospitalization care providers such as rehabilitation hospitals, nursing facilities, hospices and home health companies.

The Nursing Team

Nurses who have taken care of the patient day in and day out are an extremely valuable resource during the discharge planning process. They are able to comment, for instance, on a patient‘s mental status, stamina, ability and willingness to follow directions. They will also be able to provide valuable advice to the family based on their experience and their understanding of the patient‘s time at the hospital.

The Physician 

The physician signs off on the final discharge plan and is responsible for prescribing medications which can have a direct bearing on the patient‘s comfort and mood. The physician‘s primary goal is the patient‘s physical and mental wellbeing. 

The Social Worker

The social worker has three responsibilities: (1) to assess the patient for psychosocial factors that could impact discharge plans, (2) to help connect families with relevant community resources and (3) to provide emotional support and guidance to patients and their families. Social workers can be a tremendous resource, especially if the patient has spent significant time in the hospital or is at risk of depression or other emotional issues during the transition home.

The Skilled Therapists (OT/PT/ST) 

Occupational therapists, physical therapists and speech therapists can play a role in the discharge planning process by communicating the patient‘s capabilities and deficits to the discharge planner. These skilled therapists will also play an important role in the post-hospitalization care process.

Geriatric Care Managers

Geriatric Care Managers are trained professionals who advocate on behalf of the patient and the family. They coordinate services for the patient, acting as liaison between the different agencies that provide services to post-hospitalization patients. Many Geriatric Care Managers maintain independent practices in the community and are hired by the patient‘s family. Geriatric Care Managers usually conduct a comprehensive assessment of the patient, noting physical, social and emotional strengths and weaknesses, in order to develop a care plan and coordinate care providers for the patient.

Home Care Agencies 

Home care agencies provide non-medical care via expertly trained caregivers. These caregivers assist with activities of daily living, such as bathing, grooming, dressing, light housekeeping, medication reminders and meal preparation. Home care is often an integral component of the post-hospitalization recovery process, especially during the initial weeks after discharge when the patient still requires some level of regular physical assistance and monitoring.

Home Health Care Agencies

Home health care agencies are covered by Medicare to help patients who need the intermittent skilled services of a nurse, physical therapist, occupational therapist or speech therapist. Home Health agencies typically provide intermittent short-term services of one or two hours per day for 30 days or less.


For terminally ill patients, hospice can be a valuable resource in the discharge planning process. Hospice care focuses on the patient‘s comfort and quality of life through symptom management rather than aggressive medical treatment, which can leave the patient physically and emotionally drained. Many hospitals have their own hospice programs in addition to the multitude of independently owned and operated hospice agencies in communities worldwide.

Our Home Care Assistance Prescott Post-Hospital caregivers are professionally trained and experienced in providing post hospital care for seniors. Our caregivers can be present before our clients are discharged from the hospital to help ensure a smooth transition. If your loved one will be staying at home, in an assisted living facility, or a nursing home, our caregivers can provide 24 hours assistance with personal care. Contact us today to see you we can be of support for you or a loved one!