Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Hospital to Home

About the Transition

“Good news,” says the doctor or nurse. “You can take your mother home tomorrow.” As glad as you are to hear that your family member is well enough to leave the hospital, you might not feel ready for this move. Even if you have done this many times before, each transition from hospital to home is a little different. Your family member may need more assistance or have new medications, or your own ability to provide care may have changed.

It is important that you understand and be part of the discharge planning process. The guides in this section will help you. You can read them in any order but here is what we suggest. You can link on any of the guides here or from the menu on the right.

The Hospital-to-Home Discharge Guide will give you basic information about the discharge process and get you started asking questions. What Do I Need as a Family Caregiver? is a form that can help you understand what you will need in order to help your family member after this discharge. During a hospitalization medications often change; A guide to Medication Management will help you understand the process of medication reconciliation so that you know what has been changed and what remains the same. Going Home: What You Need to Know is a simple checklist that organizes the various tasks and supplies you will need. This is a lot to think about, but these guides will help you organize this information and plan ahead.

If your family member is referred for home care services, be sure to read Home Care: A Family Member’s Guide so that you have a realistic expectation of what services are likely to be provided.

While your family member was hospitalized, you had information about HIPAA and Advance Directives. It’s a good idea to review these. While all home care agencies are required to follow HIPAA rules on sharing information, each agency may have its own privacy rules and requirements. Our guide, HIPAA: Questions and Answers for Family Caregivers can help you with that.

Even if your family member signed an advance directive in the hospital or before hospitalization, you should review the document under less stressful circumstances. And if no advance directive was signed, now is the time to do it. The guide to Advance Directives can help you in the process.

Now that you are at home, it’s important that you review What Do I Need as a Family Caregiver? and ask the home care nurse to help you fill or update this form. A companion piece is the Family Caregiver’s Planner for Care at Home, which will give you a quick way to see who is coming when, and what tasks you need to do yourself. Also important here is the Medication Management Form, which lets you keep track of your family member’s prescriptions and over-the-counter medications.

Home care is likely to end before you feel completely ready to take over. When Home Care Ends alerts you to the plans you need to make.

Finally,we recommend that you read Emergency Room (ER) Visits to help you limit these visits to real emergencies and to help you understand the way care is provided in this setting.

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