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Hospital Discharge: Successful Transition

Returning home from a hospital stay can be challenging for older adults and their caregivers. Many people have trouble managing medications, keeping follow-up appointments, and getting the in-home supports they need. As a result, they may return to the hospital. In fact, one in five Medicare patients is readmitted within 30 days of discharge.

Help ensure a successful transition home by thinking ahead. For planned hospital admissions, this happens before your stay. For unexpected hospitalizations, start planning on the day of admission. Preparation goes a long way to help address the questions that arise during the discharge process and make a safe transition to home.

Planned Admissions

If you will stay in the hospital for at least one night for nonemergency surgery, tests, or a special procedure, planning takes several steps. If the hospital does not provide a packet of preadmission papers, ask for one. It will include basic information about any tests you need before admission, where to go on the day of admission, and what time to arrive. The packet will also outline hospital policies, like visiting hours and payment information.

Hospital Kit

Leading up to your hospital admission, it may be helpful to create a kit to take with you. Here are items to include:

Insurance information and identification card
List of your doctors with contact information as well as contact information for community services that you regularly access prior to admission
Emergency contact information
Test reports, lab results, and relevant x-ray images
List of medications (names and doses), including prescription drugs, over-the-counter products, vitamins, herbals, and other supplements
List of all allergies, severe and minor
Health care proxy and advance directives
Eyeglasses, dentures, hearing aids, and toiletries
DO NOT pack jewelry, money, or other valuable items

Emergencies

Not all trips to the hospital are planned. If you do not have time to plan and must go straight to the emergency room (ER), be sure to bring your medication and health insurance information. If possible, it is a good idea to create an ER kit, which is similar to the hospital kit, for emergencies.

Discharge

Hospital stays are often very short. As soon as a doctor determines you are medically stable, the hospital will look to discharge you. Depending on the condition, patients will transition from the hospital to home or to a short-term rehabilitation program and then home. You or your caregiver should talk to the hospital’s discharge planner, who can help you plan a smooth transition home. There may also be designated staff that will help you during your transition from the hospital and connect with you at home after discharge.

Prepare Your Home

Make sure that hospital staff orders any equipment and supplies you need prior to discharge. If you are eligible for home care services, find out what is and is not provided by the agency. Here are some good questions to ask.

Will I need a hospital bed, shower chair, commode, oxygen supply, or other equipment? If so, where do I get these items?
What supplies, like disposable gloves and adult diapers, do I need? Where do I get these?
Will my insurance help to pay for the equipment and supplies?

You may have dietary restrictions because of a procedure or medication. Ask the hospital team whether there are certain things you cannot or should not eat when you get home. This might include specific foods, such as milk, or forms of food, such as solid foods.

Your home should also be a comfortable, safe place for you to return to after a hospitalization. You may consider:

Making room for a hospital bed or other large equipment
Moving items that can cause falls, such as area rugs and electric cords
Creating a comfortable space for your caregiver
Finding a place for important information, such as a bulletin board, folder, or notebook

Health Care Tasks

If you are a caregiver, tell the hospital team if you are reluctant or unable to do certain tasks, such as wound care or changing diapers. They need to know in order to plan other assistance.

Medication Management

It is very important to take the correct medication at the prescribed time and dosage. Consider the following questions.

What new medication will I take and for how long?
Should I take the medication with meals?
Do I take the medication at certain times each day or as needed?
What are the side effects?
Can I take the new medication with what I was taking prior to admission?
Do I get the medication from my pharmacy or the hospital?
Does my insurance cover the medication? If not, are there generic alternatives?

Know What to Do

Make sure you know what to do for your care after you return home from the hospital. The following questions can help you prepare.

Are there any symptoms that I must report immediately, such as fever, intense pain, or shortness of breath? If so, whom do I call and what should I do?
Are there restrictions on what I can do, such as driving, bathing, or lifting?
Is it safe to be alone? How often should a family member or friend check in?

Despite good planning, you may have many questions during the first few days at home. Make sure you have phone numbers for people on the hospital team, any agency involved in your care, and community services.

Resources

The following resources provide useful information for discharge planning:
Hospital to Home: Plan for a Smooth Transition
https://eldercare.acl.gov/Public/Resources/Brochures/docs/HospitaltoHome.pdf
Your Discharge Planning Checklist
This checklist helps you and your caregiver make sure you have the information you need before discharge.
https://www.medicare.gov/Pubs/pdf/11376.pdf

Taking Care of Myself: A Guide for When I Leave the Hospital
http://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome/index.html
Many communities have resources that can help you and your caregivers with transportation, meals, medication management, chores, respite, and more. Find support available through your local Area Agency on Aging (AAA) and other providers by contacting the Eldercare Locator at 1-800-677-1116 or https://eldercare.acl.gov.