Transitioning from Hospital to Home

The hospital can be a frightening place. Especially if you’re the primary caregiver to an aging loved one who has just had a complicated surgery or procedure. They may have had a stroke or heart attack, infection, adverse reaction to medication, complications with their diabetes treatment, or other ailment that requires immediate medical attention. Whatever your particular case, it can’t hurt to have an ally on your side who can help you plan for the next phase of caregiving: the transition from hospital to home.

While often overlooked, this transitional period can mean the difference between a safe recovery and a quick turnaround that lands your loved one back in the hospital. Fortunately, there are allies within the hospital that can help you plan for a transition home and set your loved one on the path to a speedy recovery.

Social Workers

Social workers can assess your situation and become your family’s advocate or voice in the hospital. These individuals are capable of scheduling meetings to discuss your loved one’s care plan with doctors, nurses, and other key hospital personnel so that you are prepared when it comes time to transition home.

Hospital Discharge Planners

Discharge planners come from a variety of backgrounds, and usually have experience working as either a nurse or a social worker. According to Liberty Healthcare and Rehabilitation, “The goal when the discharge planner meets with a patient and their family is to facilitate the physician’s recommendation for the next level of care the patient would benefit from.” Depending on the situation, the physician may recommend physical therapy, in-home care, or a short-term stay in senior housing before the elder returns home. It is then the discharge planner’s job to ensure your family has all the resources needed to make an informed decision about care post-hospital stay.

Geriatric Care Managers

If all else fails, you can always hire a professional to be the care manager for your family. Geriatric care managers will conduct an in-person assessment to determine your loved one’s health needs, lifestyle habits, nutritional requirements, etc. They will then work with you to create a care plan that includes recommendations for community-based senior services.

When your loved one is dealing with complicated medical ailments and you are worried about providing the proper care when they return home, you may want to play it safe. Consider a short-term stay in senior housing, where your loved one can have access to constant supervision, rehabilitation programs, medication management, and other helpful services as they recover after a hospital stay.

Seniorly has a gerontologist on staff who provides free care consultations for elders and their families. She is an expert in senior living options in California, and has years of experiencing helping families locate the care communities that are right for them. You can email us at to request a meeting or call us directly at (415) 570–4370.


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