A Caregiver’s Guide to Discharge From Hospital to Home Care

by Nathan Costiuc, MSN, APRN, FNP-BC

The moment has finally come. Your loved one who’s been lying in the hospital bed for days is about to be discharged home. No more IV’s, multiple night-time awakenings, or hospital food! Patients typically ache to get back to their normal environment, so hearing the word “discharge” can be exciting. But as a caregiver faced with the prospect of being responsible for their home health care, you begin to wonder if everything is truly in place for a safe discharge. The cause for extra consideration is well-founded.

2019 study from Penn Medicine researchers published in JAMA Internal Medicine studied 17 million Medicare patient discharges. They discovered that patients discharged to home with home health care services were 5.6 percentage points more likely to be readmitted to the hospital within 30 days than those discharged to a skilled nursing facility.

So how can you be more prepared to get your loved ones home safely? Here are some practical steps you can take to make sure they are ready.

Familiarize yourself with “the case.” 

The best patient advocates are typically patients themselves and the loved ones around them. Because of this, you’ll want to know as much as possible about the primary diagnosis (or diagnoses) for which your loved one has been admitted to the hospital, which specialist physicians are on the case and what they’re each responsible for, the significance of any procedures and diagnostic studies that may have been performed during their stay, and what discharge typically looks like for any given diagnosis.

All of this may require a bit of research on your end. General health information is available online from reputable sources, but you can also consult government agency websites like the one from AHRQ specifically designed to improve the experience of hospital discharge. These resources may help you get a sense of whether or not a discharge is safe or if it should be delayed until it will be. And if it all begins to a feel a bit overwhelming, you can…

Talk to your nurse!

Nurses can help you tailor the disease-specific information you’re looking for to ensure a safe discharge. While it’s also helpful to speak with your physician, it may be challenging to catch a doctor for questions for more than a few minutes during their rounds. Here a nurse - especially one who’s been with your loved one for a few days - can be your best ally. They can consult on your loved one’s medical status, consolidate information from all the specialists involved, share their observations on your loved one’s level of independence, and provide relevant documentation if necessary.

Some questions to consider discussing with the nurse are:

  • If my loved one had to go home with me today, do you think they’d be ready, or would you be concerned?
  • Considering my loved one’s functional status, what level of assistance do you think they may need?
  • Do you know of any relevant clinical findings that haven’t been addressed during their stay? (Your nurse should know of any concerning lab results, vital signs, or imaging findings.)

If the feedback from your nurse indicates some level of apprehension from a clinical perspective or concern that the patient might need more care than you could reasonably provide in your context, you’ll want to prevent or delay the discharge until you have better answers.

A simple way of doing this is having a collaborative, frank discussion with your nurse or the floor’s charge nurse. They not only have the power to delay what they perceive as an unsafe discharge, but are also the best mediators to inform the hospitalist (ie., the main general doctor on the case who is ultimately responsible for discharge) or other specialist physicians of their concerns.

Consider the context of care.

Depending on the reason for admission, you may need to be a part of coordinating certain services to be delivered at home. Consider the following common scenario: a patient is admitted for an infection that is resistant to treatment and spends about a week in the hospital. Doctors decide that the patient can go home but will need to continue IV antibiotics and start physical therapy to regain the strength they lost while they were admitted.

In this scenario, a caregiver could expect to be a part of coordinating the following before discharge:

  • Making sure the patient has long-term IV access (these are more serious than IV’s and may be called PICC lines or midlines).
  • Having an IV infusion agency deliver the relevant antibiotics and schedule the first infusion with a nurse.
  • A pre-discharge wound care nurse visit in case any surgical procedures were performed for the infection.
  • Early communication with a physical therapy practice to ensure your loved one’s quick return to function.
  • A screening visit from a home health care nurse to determine if additional services are needed.

Patients and their caregivers often work with case managers to organize these services, and this could be a good moment to identify whether a crucial post-discharge resource will be delayed. Invariably, a delay of time-sensitive services may be a strong reason to postpone the discharge itself.

Make use of your resources and medical technology.

After ensuring a safe discharge from the hospital to care at home, caregivers often find that more is required of them than before the hospital visit. This is because patients often experience a decline in functional capacity for activities of daily living.

But you don’t have to go it alone. Consider setting up a collaborative environment of care with your siblings or other family members. This will require thoughtful discussion, an understanding of limitations, and the navigation of potentially tricky relationships.

And where the limitations of everyday life can make home health care situations like this challenging, you may also consider how modern technology can help. Medical technology for remote patient monitoring of your loved ones at home can help increase safety, foster independence, and have a great impact on physical and emotional health. But older adults have long been disillusioned with technology that feels like it wasn’t designed for them.

Tools and Services such as Livindi can help. With video calling, helpful care managers, and home monitoring tools that were designed with older adults in mind, you can make the practice of regular communication with your loved ones easy.