When a loved one is hospitalized, the main focus of the family is being there for their loved one to make their treatment and recovery time in the hospital the best and most effective it can be.

Spending time with the patient to help ease their stress, alleviate their fears, and provide for their practical needs is crucial at this time. The hospital time can demand a total focus and leave little time or energy for anything else. While lending emotional support to the patient, it will be necessary for a friend or family member, especially one with power-of-attorney, to oversee the financial aspects of the hospitalization.

As soon as the initial admission procedures are completed and the medical team has a diagnosis and treatment plan, the family member(s) need to start planning for the best in home care services for long-term care, and whether home care after hospital or transitional care will be needed.



A discharge team will be ready to facilitate the transition from hospital to home. The first decision to be made is whether the patient will be transported to a rehabilitation facility for further strengthening and therapy or allowed to have home care after hospital discharge.

The patient and family should make their wishes known and ask for a comprehensive discharge and treatment plan to guide them after hospital discharge. Carefully following discharge orders optimizes the healthcare patients receive.

Some issues that need to be evaluated and planned for to assure better patient centered care outcomes include:

  • Obtain needed durable medical equipment such as hospital beds, walkers, bedside commodes, etc. and have them in place before discharge
  • Get a list of names and phone numbers of care providers the patient will be seeing after going home
  • Receive instruction from hospital staff in performing tasks such as changing wound dressings or administering injections to the patient at home
  • Ask for information about dealing with the specific condition the patient has and how to avoid future problems
  • Request a social worker to help with transitional care at home
  • Obtain complete discharge instructions and ask questions as needed



Spending time in a rehabilitation facility will likely be recommended if the patient has experienced a stroke or undergone a hip replacement and needs long-term care.

The care provider may recommend up to 30 days in a facility. Medicare will pay for three to four hours a day with a physical therapist, speech therapist, or occupational therapist.

A Registered Nurse oversees patient care at rehabilitation facilities and each patient benefits from the services of Certified Nursing Assistants. If the patient’s condition is serious enough to require round-the-clock skilled nursing care or if the patient is showing progress with treatment, several weeks of care in a facility may be covered by Medicare.



When considering admission to a rehabilitation facility, some disadvantages need to be considered:

  • Risk of contracting illness or infection from other patients
  • Long-term care in hospital settings may lead to depression and make the patient feel institutionalized
  • Patient may be bed bound for extended periods of time
  • Possible staffing shortage limits individual attention
  • Insurance coverage is not guaranteed. Patient will be continually assessed for eligibility



On the day the patient returns home, arrangements must be in place for continuous care and assistance. Family members may be able and willing to take turns being with their loved one to provide the help they need, but sometimes the job becomes overwhelming.

Lacking proper training to care for someone with increased medical needs may leave questions unanswered and crucial care elements neglected. Getting the patient to follow-up doctor appointments, especially if there are mobility issues, can be difficult when added to other necessary responsibilities.

The last thing the patient or family wants is another hospitalization coming soon on the heels of the previous one.

Hospital readmission rates show that the healthcare patients receive in the immediate post-discharge period have a major bearing on whether or not the patient will return to the hospital or make a successful recovery at home.


The Role of a Home Health Agency and Professional Caregiver

Home Health Care Agencies offer home care services that optimize patient centered care outcomes. If an agency is chosen before discharge, medical social workers and discharge planners can contact the agency and begin coordinating care before the patient returns home.

A highly trained caregiver can be introduced to the patient and family in the hospital or at home. If at any time it seems that the caregiver is not a good match, the agency will gladly choose another until a compatible person is found.

There need not be a lapse in caregiver availability at any time as the home care agency can provide a replacement to cover any absences.

The caregiver can help with transportation to doctor appointments, prescription pick-up, and grocery shopping, light housework, medication reminders, assistance with mobility, and personal care such as showers and dressing.

Status reports will be shared regularly between home and agency and the caregiver will provide a report of the patient’s progress to family members as well.

During the first 72 hours at home, the patient and family members may feel confused and exhausted from the hospital stay. Hospital readmission rates reveal that many patients return to the hospital due to medication errors, falling, or failing to maintain proper nutrition.

At a time when the needs are greatest, professional caregivers can provide that helping hand to start the recovering patient and their family back on the road to optimal health and vitality.