How to Transition Home After Leaving a Medical Facility

When you or a loved one leaves an acute care hospital, nursing and rehabilitation center or a long-term acute care (LTAC) hospital, recovery does not end. In many ways, it begins — whether you are going to another care setting or home. Learn more about how to transition home after leaving a medical facility.

Transitioning Home After a Hospital Discharge

Many studies have shown that the period after hospital discharge, or the transition between acute care and a less intense level of care, represents one of the times when the patient is most vulnerable.¹

“Family conferences with our interdisciplinary team of care providers help our patients and families become oriented to the continuum of care needs that they have, and their progress along that continuum,” says Sandra Morgan, Chief Clinical Officer at Kindred Hospital Bay Area in Tampa Bay, Florida. “It is very important to them to have our experts give them advice on next steps and planning.”

There are several important ways that you can take an active role in making sure you or a loved one’s discharge is not an end. Here are three steps you can take toward further recovery and meeting your personal objectives at the next level of care:

1. Plan for Leaving in Advance

Like Kindred Hospital Bay Area in Tampa Bay, many facilities offer discharge planning resources or a dedicated staff member to aid patients with plans. Take advantage of these resources, ask the right questions and voice your concerns.

• Make sure you know as much as you can about your or your loved one’s illness.
• Know what medicines you will be taking and ask about how or if they might interact with medicine you were taking before you were hospitalized (or herbal medications or supplements you might have been taking). What are the possible side effects of the medication and how can those be managed?
• If you are going home, ask if you will need to make accommodations in your home for your conditions — Will you need a ramp for a wheelchair? Should you remove rugs or be careful around pets that may jump?
• Make sure you have a clear plan for how you will get to your follow-up appointments if you cannot drive yourself. Ask about agencies in the community that might be able to help.
• If you are going to a skilled nursing facility, utilize information about what to look for in making your choice.
• If a family member is going to serve as a caregiver, does that person understand the demands of the position and feel prepared to undertake it?
• Understand how your information will be conveyed to the next care setting.

2. Maintain Realistic Expectations

It’s common for patients or their family members to expect a full return to their pre-hospital selves after a health event. However, this is sometimes not possible, and not maintaining realistic expectations about recovery can lead to disappointment and depression.

At minimum, many patients will need to make lifestyle changes to prevent the kind of event that precipitated the hospitalization from happening again. These changes may include dietary or exercise modifications. At the other end of the spectrum, many patients require extensive additional treatment, monitoring or rehabilitation. Before leaving the hospital, make sure you understand the extent of improvement that is expected to take place, and what further therapy or treatment is needed to ensure the best outcome.

3. Know the Pitfalls So You Can Avoid Them

Here are some of the largest challenges patients experience after leaving a medical facility:

• Medication errors (incorrect dosing, missing dosages or mixing medications that should not be mixed)
• Establishing an appropriate caregiver
• Is a family member able to provide the right level of care or do you need home health services?
• Is another inpatient setting needed as you move through lower levels of care?
• How will care be paid?
• Does your insurance and/or Medicare cover the cost of your care?
• Did you ask the right questions?
• Some patients have concerns that they are not ready for discharge. This may be valid, or it may just be nervousness about what’s to come. If you have concerns, ask the hospital staff.

Patients and their loved ones can be important participants in this team process with the goal of excellent outcomes.

“Connecting the dots throughout a patient’s episode of care leads the way to safe, efficient treatment from their admission at a long-term acute care hospital through their discharge home,” said Derek Murzyn, Chief Executive Officer of Kindred Hospital Greensboro in Greensboro, North Carolina. “Treating appropriate patients at the appropriate level of care at the appropriate time is the best way for us to leverage clinical resources and physician expertise to offer patient-centered, comprehensive care.”

Using the tips in this article can help you prepare for leaving a medical facility, maintain realistic expectations for your transition and know potential challenges you may face so you can create a plan to prevent them.

¹Okoniewska BM, Santana MJ, Holroyd-Leduc J, Flemons W, O’Beirne M, White D, Clement F, Forster A, Ghali WA. “The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool.” BMC Health Serv Res. 2012 Nov 21;12:414.

Do you have experience transitioning a senior loved one home after a hospital stay? Share your stories with us in the comments below.

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