Post Discharge Home: Seniors are rarely 100% recovered


Discharge home from Hospital or Rehab to HomePost Discharge home, you may find your elder loved one’s Discharge Plan is quite complicated or they may not be up to dealing with the details. The hospital or rehab Discharge Planner may review the plan but it is likely not really heard or understood. Your parent may live alone, not be allowed to walk or drive, be cognitively impaired or be the primary caregiver for someone else. No one wants a preventable re-admission. They need help; therefore, a “Transition Home” plan is needed.

It is recommended to choose a licensed Home Care company that has some type of “Transition Home” plan for when the discharge occurs and the caregiver begins care.

Can your older mother or father understand the Aftercare Plan?

Why Home Health Care? We are mindful of all of the pieces it takes to produce a positive outcome.

How do we make this happen? A Registered Nurse will:

  • Consult with the Discharge Planner and patient to review D/C PlanTake the patient home or meet the family there.
  • Arrange for the prescription medications to be ordered, picked up or delivered. Dispose of discontinued meds.
  • Educate patient and primary caregiver about med doses & side effects.
  • Set up a weekly pill box.
  • Make the follow up appointment with the primary physician and others.
  • Conduct a Home Safety Evaluation and provide recommendations.
  • Check & discard spoiled foods from fridge and prepare a light meal.
  • Assess need for and organize private care in home.
  • Refer to our Social Worker for follow up about services/benefits needs.

Hiring a licensed nurse LPN or RN is a good way to help get the return home off on the right foot. Hiring an aide HHA or CNA is a good way to see how you or your family member manages once back home – helping with ADL personal care and household chores – cooking, laundry, shopping etc.  The first 72 hours are very important and very busy as Medicare Home Health Nurses and Therapists begin their visits. Nighttime is especially a time not to be alone the first couple of days. It is when falls happen; missed appointments and medication doses are missed. A little help goes a long way for a successful return home and recovery. Remember, even when your mother or father is looking forward to being home again, there is some anxiety involved. They are going from a very safe and catered to environment, back to fending for themselves.

                                                                                   Welcome Home