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Hospital Discharge Care

Successful transition from hospital or facility care to home...

Hospital readmission rates for seniors can be as many as one in four, because understanding and following hospital or facility discharge orders and  managing  medication changes can be very challenging to seniors and their families. Our transitional care program is designed to provide the support to assure a safe and successful discharge after surgery or hospital stay. Including preparing the home, setting up a care plan, providing personal care or enhanced home care if needed, reviewing your medications and implementing medication management systems, and follow up with your primary physician!  


Hospital discharge services may include:

  • Arrive at the home the day of discharge to help the client “settle in”.

  • Evaluate and prepare the house for a safe hospital discharge.

  • Can provide follow-up physician visit assistance.

  • Provide personal care or enhanced home care if needed.

  • Create a “preliminary care plan” for the first 48 hours of care.

  • Educate the client and family on what to expect and what to watch for.

  • Review the medications and treatments that have been ordered and set up a medication system.

  • Inform the client and family of when to call our “24 hour hotline”.

  • Accompany the client and family to the PCP appointment.

  • Review medications and compliance with discharge orders and any new.

  • Create laminated medication sheet for the home.

  •  “24 hour hotline” available to answer questions and contact appropriate healthcare professionals.

  • Medical Records packet and POLST put together for client/family use.

  • PCM continues to educate client and family and focuses on future plans.

  • PCP receives weekly progress reports and final report.

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