Navigating a Smooth Transition From Hospital to Home Care

When being discharged from the hospital, a high percentage of people face emotions such as anxiety and fear, which can make the process of transitioning from hospital care to safe and adequate home care overwhelming. However, if an effective strategy is put into place before discharge, it doesn’t have to feel that way. As a physician with over 35 years of experience in emergency, palliative, and end-of-life care, I have helped hundreds of people plan for a smooth transition from hospital to home and receive the coordinated care they need to be safe and comfortable.

When you are living with a complex or terminal illness, it can be so meaningful to be at home, in familiar surroundings, and around family and friends. Leaving the hospital or another care facility can be scary and stressful because there is limited access to adequate and responsive in-home medical care that can ensure that you or your loved one is comfortable and safe. A few of the questions that might keep you awake at night when you or a loved one is preparing to transition home from the hospital are:

1. How do I find help I can trust?
2. Can treatments continue at home that are being given in the hospital, like IV fluids, antibiotics, etc.?
3. Who do I call when questions or concerns arise?

Answering these questions and developing a strategy before being discharged from the hospital will help ensure a smooth transition to home care.

Confidence to Manage Care at Home

Actively participating in the hospital-to-home transition is an important element of gaining control and feeling confident in managing care at home for you and your loved ones. Hospitals provide acute care, but once you are discharged, the hospital team disengages completely and the responsibility falls on family members, caregivers, and other care providers. A strategy for how to navigate the transition will ensure that appropriate medical treatments, medications, and therapies initiated in the hospital will continue at home without disruption.

Complex and terminal illnesses require input from various specialists, including primary care and specialist physicians, palliative care teams, home health providers, etc. Poorly managed transitions from the hospital to home can lead to confusion and overwhelm, as well as physical decline, medication errors, or missed or incorrect treatments, which increases the likelihood of having to return to the hospital. Receiving clear guidance on managing an illness at home will help improve overall health outcomes and will prevent unnecessary re-admission to the hospital.

3 Steps to Create a Hospital-to-Home Care Strategy

Coordinating care among healthcare providers, caregivers, and family members is especially critical for anyone living with a complex or terminal illness. Pain and other symptoms must be adequately managed. When a roadmap of the responsibilities, necessary resources, and support systems is strategically put into place upon discharge from the hospital, it eases the burden on everyone and enhances the quality of life for all.

The following three steps will help you develop a strategy to plan a safe and effective hospital-to-home discharge:

Step 1: Request an assessment with an experienced team (that includes a physician) before being discharged from the hospital to review options for care at home.

Step 2: Create a discharge plan that is coordinated with all healthcare providers, and the loved ones who will be involved in the discharge and ongoing care at home. Make sure that the hospital team is aware of and comfortable with the plan.

Step 3: Establish ongoing care at home that includes: routine and urgent physician visits with your physician, routine and urgent nursing visits to explore and address any changing needs, appropriate supportive therapies such as physical and occupational therapy, wrap-around mental, emotional, and spiritual support for you and your loved ones, and integrative therapies such as massage, music therapy, reflexology, Reiki, etc.

Completing these steps will give you a solid plan and create a much safer and more comfortable environment for everyone. Equipping yourself with information, resources, and support upon discharge is necessary for those living with a complex or terminal illness. These steps allow you to be proactive and avoid unnecessary challenges and complications once discharged from the hospital. You will be less likely to return to the hospital and be properly cared for in the comfort of your home, surrounded by your loved ones.