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Hospital to Home Care Transition Program

Clients & Families:

Transitioning home from a hospital setting, rehab, or skilled nursing facility can be a cumbersome process but luckily, we can take that off your shoulders. Whether you want to go elsewhere or straight home, you want someone who has your best interest and is on top of the details that matter. 

Our registered nurse will meet with you to discuss specifics and complete the necessary paperwork before we can arrange to have you home. If your trip requires special equipment or luggage, we’ll make arrangements for that as well. We help make it easy for you to quickly adjust back to your daily life, hence minimizing the risk of hospital re-admissions and promoting a healthy positive environment so you can get back to speed quickly and effectively. We can also do minor clean up, groceries and run errands for you prior to your arrival so your home is ready and comfortable for you when you come home. 

The following services are typical during transitional home care, though the exact program would depend on your situation and transition of care requirements:

  • Meet with clients at the hospital or facility and obtain discharge instructions
  • Update care plan as appropriate, ensuring adherence to the prescribed regimen
  • Pickup any medications, prescriptions, clothing, groceries, among other necessary items
  • Safety recommendations around the home, clearing the path, reducing hazards & other risks
  • Ongoing home care and companion support
  • Medication reminders, exercise prompts, emotional well-being and physical support
  • Encouraging wellness, proper hydration and balanced nutrition while following your diet restrictions suggested by your physician or discharge planner
  • Educate family members and caregivers about appropriate care procedures, applicable situations, and red flags to minimize risk for chronic conditions
  • Continuous updates and communications with your loved ones, physicians, discharge planners, among other health care professionals as needed

Preparing for the Transition Hospital or Rehan-to-Home 

Implementing a few straightforward strategies can guarantee a seamless transition of care home for you or your family members, fostering healing and recovery for the future.

Involve Family in the Planning Process

Involving family members in the discharge planning process ensures a clear understanding of the physical, medical and other conditions and treatment plan. Given that patients in a hospital setting are often overwhelmed, having family support can alleviate the burden of managing the planning process alone.

Get Any Necessary Equipment

Upon discharge, your plan may include various recommendations, prescriptions, and treatment protocols that could necessitate specialized equipment. For instance, individuals recuperating from injuries might require resistance bands or training equipment to aid in at-home physical therapy. Similarly, those with respiratory conditions may need oxygen tanks or breathing apparatuses among others.

Keep Up with Follow-Up Visits

Ensuring attendance at follow-up appointments and primary care visits is crucial for patients to effectively track and monitor their condition over time. Often, individuals return home and become complacent about their health status, increasing the risk of avoidable hospital readmissions in the future.

Start Professional Home Care

Professional home care services can help you stay on top of the entire transition process. A transition home is often much more conducive to recovery, as you have a trained provider within the house to help with the next steps of the treatment process.

Understanding the Discharge Process

A well-planned and executed hospital discharge is crucial for a patient’s ongoing recovery and adherence to post-discharge care.

The discharge conversation, led by both the attending clinician and discharging nurse, must include all relevant information to ensure a safe departure from the hospital and successful follow-up.

It’s essential to involve a family member, friend, caretaker, or home health aide in the conversation. Key points to discuss include:

  • Understanding the reasons for the current admission and hospitalization events.
  • Clear comprehension of medical conditions and outpatient care instructions.
  • Explanation of potential warning signs and symptoms.
  • Provision of a 24-hour emergency phone number.
  • Identification of the post-discharge care provider with written contact details.

Managing Medications at Home

More than 1.5 million preventable adverse drug events occur annually in the United States. Implementing a strategy is vital for creating a comprehensive and accurate medication list. 

This list forms the basis for addressing medication reconciliation and management issues. The process involves multiple steps, including monitoring, reconciling medications, and ensuring patients achieve desired outcomes. 

In conjunction with your doctor or medical provider, it necessitates a thorough review of medications and potential side effects to develop treatment plans and monitor safety and efficacy.

Arranging Home Care Services

1. Shortlist Services

To initiate your search for home care, a valuable starting point is researching care providers. Recognizing that looking for the ideal care provider can be overwhelming, you may want to create a short list. 

2. Call and Discuss Transition Care Requirements With Manager

After compiling a shortlist of potential home care providers, we advise contacting them to address any queries you may have. Key points to discuss before selecting a home care provider include:

  • Inquiring about their capacity to accept new clients.
  • Confirming if they can accommodate the frequency and duration of visits you require.
  • Ensuring they can meet your specific care needs.
  • Clarifying the provider’s pricing structure.
  • Verifying if they can maintain the consistency of care needed

3. Arrange a Face-to-Face Consultation/Assessment

After shortlisting potential care providers, the next step is arranging face-to-face meetings with each service’s Care Manager. 

During these meetings, the Care Manager will visit your home to meet you and any family members you wish to include. The purpose is to conduct a risk assessment of your home to ensure it’s safe for careers and discuss care requirements in detail.

This consultation allows you to learn more about the provider and enables them to fully understand your needs. Following the meeting, the care provider will create a personalized care plan, which will be explained further in the next step.

4. Care Plan Created

After a face-to-face consultation with the Care Manager of a home care service, they will utilize their understanding of your care needs and preferences to create a customized Care Plan for you or your loved one. This plan will outline specific care requirements, including mobility and daily routines, and will be regularly monitored and updated to accommodate any changes in individual needs.

The home care company will then match you or your relative with a caregiver or caregivers who they believe are best suited to provide the necessary support.

Creating a Safe and Supportive Home Environment

  • Ensure Proper Home Safety Measures: Begin by implementing essential home safety measures, such as installing handrails and grab bars in critical areas like staircases and bathrooms. Adequate lighting and removal of tripping hazards are also essential.


  • Adapt the Living Space for Mobility: Consider installing ramps or lifts for accessibility and removing obstacles to create wider pathways. Rearrange furniture and opt for adjustable-height options to promote better manoeuvrability.


  • Optimize Bathroom Safety: Install grab bars and non-slip mats in the bathroom, and consider raised toilet seats or commode chairs for added convenience. Set water temperatures at safe levels to prevent scalding accidents.


  • Enhance Security Measures: Invest in a reliable home security system with door / window sensors and motion detectors. Doorbells and intercom systems can improve communication and identification of visitors, while outdoor lighting and secure locks provide additional safety.


  • Foster Comfort and Emotional Well-being: Create a comfortable living environment with cosy seating arrangements and temperature control options. Personalize the décor with familiar items and designate spaces for relaxation and hobbies to promote emotional well-being.


Follow-up Care and Appointments

  1. Monitoring Recovery Progress: Follow-up visits enable healthcare professionals to track a patient’s healing process post-treatment or surgery, identifying any potential complications early on.
  2. Medication Management: Medical providers can review and adjust medication regimens during follow-up appointments, ensuring effectiveness, addressing side effects, and making necessary modifications.
  3. Preventing Complications: Follow-up visits allow prompt detection and management of post-hospitalization complications, such as infections, to ensure optimal healing and recovery.
  4. Addressing Concerns: Patients can discuss any lingering questions or concerns during follow-up appointments, receiving additional information and support to enhance their understanding and confidence in their recovery journey.
  5. Rehabilitation and Therapy: Follow-up care often includes referrals to rehabilitation services or therapy sessions to aide in physical function and overall well-being. Healthcare providers assess the effectiveness of these interventions and make adjustments as needed to support patient recovery.

Health Care Professionals:

For case managers and discharge planners, supervised care provided by a reputed home care agency that is proficient in transition from hospital or rehab to home can minimize re-admissions, lower medical costs and enhance quality care. 

We have had decades of experience providing seamless transition programs. We would love to work with your clients and their families to improve patient outcomes and recovery. 

Please call our office for more details at 561-742-2532 or email us at