Navigating Hospital-To-Home Care Transitions

David Nelson

Moving a loved one from the hospital back to their home can be a difficult transition for family caregivers.  When these transitions are not properly planned and managed, the patient often ends up back in the hospital.  Approximately 20% of Medicare patients are readmitted to the hospital within 30 days of discharge and up to 75% of these readmissions are preventable according to the Agency for Healthcare Research & Quality.
Recent studies released by the Journal of the American Medical Association have identified poor care transitions from hospital to home as one of the primary causes of high hospital readmission rates.  One of the biggest challenges in care transitions is that family members, often with limited caregiving training or experience, are suddenly asked to manage their loved one's care.  This is very common as up to 80% of all chronic disease care is provided by family members.
What are some things that a family caregiver should keep in mind to create a smooth transition from hospital to home?  Here are a few ideas based on suggestions from Medicare, AARP and


  1. Understand your loved one’s condition: In a recent study at Yale, only 57% of patients knew their diagnosis.  Both the patient and the loved one should work with doctors and nurses to understand the patient’s condition.  This way you know what your loved one’s limitations will be and if there are certain symptoms that you should be reporting to a health care professional right away.  A good transition plan must start with a strong understanding of the patient’s condition and needs.
  2. Pay special attention to medication: The population that is most at risk for readmission is those that take more than 5 medications. As the amount of medication prescribed increases, compliance decreases.  If your loved one takes multiple medications, make sure that you have a plan to help him or her take the right dose of the right medicine at the right time.  Also, understand the potential adverse effects of medication.  The same Yale study mentioned above found that 90% of patients did not know the possible adverse effects of medications.
  3. Establish communication lines: Make sure you have the contact information for doctors, pharmacists, in-home care providers and others involved in your loved one’s care.
  4. Bring in help when necessary: In-home care providers can provide critical support during transitions.  Geriatric care managers can help you navigate the variety of decisions you will have to make and serve as an advocate.  It’s a stressful time for many family caregivers and doing it alone can be very difficult.
  5. Home Modification & Equipment: If necessary, find a service provider to modify the home so your loved one can live comfortably and safely.  This article gives you some ideas of the modifications you might want to make.  Based on your loved one’s condition, explore different technology solutions that can help him or her stay connected to friends, family and health care providers.

Here are some good checklists, guides and tips as you prepare for your loved one’s transition from the hospital to home: 

Next Step in Care Hospital to Home Guide

AARP Prepare to Care Guide

Medicare Hospital to Home Transition Tips

Medicare Hospital Tips for Caregivers

Medicare – What Every Caregiver Should Know

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