Hospital to Home Care

The handover nobody manages

A discharge is a transfer of responsibility from an organization with a hundred staff and a complete record to a household with one exhausted relative and a printout.

The hospital is not being careless. It hands over what the system asks it to hand over: a discharge summary, a medication list, a follow-up appointment, sometimes a referral. What it cannot hand over is everything the ward knew, that he gets confused in the evenings, that he refuses to use the frame, that the wound looked worse on Thursday, that he had not had a bowel movement in four days.

That knowledge simply stops at the door. Everything that goes wrong in the following week tends to trace back to it.

Start with the medications, genuinely

If you do one thing from this page, do this one.

Get out every pill bottle in the house, including the ones in the bathroom cabinet and the kitchen drawer. Put them next to the discharge medication list. Compare them line by line.

You are looking for three things.

• Drugs that were stopped in hospital but are still in the house: People resume them out of habit. This is the most common and most dangerous discrepancy.
• Two drugs that do the same job: The hospital may have switched someone to a different blood pressure medication or blood thinner. If the old one is still on the shelf and nobody said to stop it, both get taken.
• Doses that changed: The same drug at a different strength, or twice daily instead of once. Easy to miss because the name is familiar.

What to do with the discrepancies

Throw away, or clearly box up, everything not on the discharge list, and check with the pharmacist or prescriber before discarding anything you are unsure about.

This is not a marginal exercise. Medication discrepancies after discharge are one of the best-documented causes of readmission, and reconciling them takes half an hour at a kitchen table.

The first seventy-two hours, in order

• Before you leave the building: Ask for the discharge summary, the complete medication list, the wound care instructions if there are any, and the name and number of someone you can call. Ask directly: what should I be worried about, and what do I do if I see it?
• The first night: Decide before you get home who is in the house and what happens at 2am. This is the shift families most often assume will be fine and most often is not. If someone is unsteady, confused, or has a catheter or drain, the first night is the one to cover properly.
• Day one: Does the equipment actually work in this house? The commode, the frame, the bed rails, the shower seat. Is the route from bed to bathroom clear at night. Has anyone eaten a proper meal. Has every medication been taken correctly once.
• Day two: Is the follow-up appointment booked, and can they physically get to it. Transportation is the reason follow-ups are missed more often than forgetfulness. Confirm the ride now, not the morning of.
• Day three onwards: Watch for the pattern rather than the incident. Eating less each day. Sleeping more. Withdrawing. Slightly more confused than yesterday. That is what deterioration actually looks like, gradual and easy to normalize if you are in the house every day.

Know the red flags before you need them

Every condition has its own. A heart failure discharge has different warning signs from a hip replacement or a stroke.

Ask the discharging clinician for three specific things to watch for, written down, and what to do about each. Most will do this readily if asked directly and almost none will offer it unprompted.

Then make sure whoever is in the house actually knows them. A caregiver who does not know that sudden weight gain matters in heart failure will not report sudden weight gain.

Our transitional care is deliberately front-loaded, with more support in the first week and less afterwards, rather than a flat schedule.

Skilled or non-medical?

Both, usually, and they are funded differently.

If a physician has ordered skilled care, meaning wound management, IV therapy, injections or clinical monitoring, that is skilled home health care, and Medicare may cover it for the episode.

The rest of the week is non-medical home care: help getting up, meals, supervision, transportation, being there overnight. Medicare does not fund that, and it is often the part that actually prevents the readmission.

Most households need a small amount of the first and more of the second. We will set out which is which before anything begins.

What we can tell you about timing

A registered nurse can review a discharge summary within 24 hours of receiving it.

From a discharge call, the typical time to a first visit is four hours. That is the fastest response we offer on any service, because this is the window where the risk sits.

Where we provide hospital to home care

Hospital-to-home care across Palm Beach, Broward, Miami-Dade, Martin, St. Lucie, Indian River and Okeechobee counties.