Navigating the Transition from Hospital or Rehab to Home: How In-Home Care Aids Recovery

The journey from hospital to home is a critical phase in the recovery process. Without proper planning and support arrangements, it can lead to complications, delays in healing, or even worse hospital readmissions. 

Typically, you are planning for a loved one, a Senior person, that is “home bound” and has already been through a fairly difficult Hospital journey – for example, they had hip replacement surgery after a Fall; or they have suffered from a brain bleed or Stroke and are being sent home after a Hospital admission, and a 2 week stay at a Rehab Center. 

Navigating the transition from hospital to home requires careful coordination, a safe environment, and personalized care approach. Experienced and planful In-home care arrangements can play a transformative role in this process, ensuring a smoother and safer recovery for patients, and the ability to not lead to readmissions into Hospital or Rehab.

Key Takeaways

• In-home care improves recovery outcomes by offering personalized clinical and emotional support.
• Proper hospital discharge planning prevents complications and ensures continuity of care.
• Support from highly experienced professional caregivers, and active family involvement  reduce the risk of hospital readmissions.
• Contacting professional in-home care services like Care Mountain ensures comprehensive post-hospital support.

The Importance of Discharge Planning from Hospital or Rehab Center

A well-structured discharge plan from a Hospital, Skilled Nursing Facility or Inpatient Rehab center is critical and it lays the foundation for coordinated continuity of care, and a successful recovery at home. 

A well orchestrated and well coordinated discharge planning process has multiple benefits that include for example:

• Reduces hospital readmissions.
• Improves recovery outcomes and quality of life.
• Enhances patient satisfaction and caregiver confidence.
• Minimizes the risk of complications, such as falls or medication errors.

Discharge planning ensures that patients and their families are well-prepared to manage care at home. Key elements of a good discharge plan include:

• Medication Management: Understanding what medications to take, when, and in what dosage. It will review all medications to ensure a complete and accurate list of medications is provided. It aim to simplify the regimen by adjusting medications for ease of use and avoiding potential interactions.
• Coordinate Follow-Up Appointments: Scheduling visits with primary care physicians or specialists, and therapists. Ensure family and caregiver prioritize these.
• Dietary Guidelines: Tailored meal plans to aid recovery.
• Physical Therapy: Exercises or treatments to regain strength and mobility.

Professional caregivers can bridge the gap between hospital, skilled nursing facility or Inpatient Rehab centers to the home by ensuring each and every one aspect of a Senior’s discharge plans are followed meticulously everyday.

Benefits of In-Home Care After Hospitalization

Personalized Medical Support

In-home caregivers provide vital medical assistance, including:

• Managing medications and monitoring for side effects.
• Assisting with wound care and dressing changes.
• Helping patients adhere to therapy schedules.

Enhanced Safety and Mobility

Many post-hospital patients struggle with mobility. In-home caregivers:

• Provide assistance with walking and moving safely.
• Help prevent falls by offering support during activities like bathing or dressing.
• Identify and mitigate potential hazards in the home.

Emotional Well-Being

Recovering at home can be isolating, leading to anxiety or depression. Caregivers:

• Offer companionship and emotional support.
• Encourage social interactions with family and friends.
• Help patients regain confidence in their abilities.

Steps for a Smooth Transition from Hospital to Home

Prepare the Home Environment

• Remove tripping and Fall hazards like rugs or cords.
• Install grab bars in bathrooms and handrails on stairs.
• Ensure good lighting in all areas, especially hallways and entryways. Use motion sensitive lights in areas like bathrooms and closets

Coordinate Care Plans

• Work closely with healthcare providers to understand recovery needs.
• Create a schedule for medications, therapy, and meals.
• Arrange for professional in-home caregivers to provide specialized support.

Communicate Effectively

• Maintain open communication between family members, caregivers, and medical professionals.
• Use tools like shared calendars or apps to track appointments amongst family members, and plan who is taking your loved one for the appointments.

Common Challenges and How In-Home Care Overcomes Them

Adjusting to New Routines

Returning home after a hospital stay often means adapting to new routines, especially when changes in functional mobility, speech and independence are significant. Professional caregivers ease this process by:

• Helping patients establish consistent daily schedules that incorporate the changes in your Loved one’s mobility, speech, fine motor skills
• Ensuring adherence to therapy and medication regimens.  When multiple weekly sessions of physical, occupational and speech therapy are needed, these can be potential sources of burnout and fatigue for your loved one. An experienced caregiver will balance both the aspects – being their friend and yet keeping them motivated and going. 

Managing Medications

Patients may need to take multiple medications with specific instructions. In-home caregivers ensure:

• Proper dosage and timing of medications. For example, before or after meals, spacing the timing and sequences of medications
• Monitoring for adverse reactions or side effects.

Preventing Complications

Complications like infections or re-injury are common. In-home caregivers:

• Monitor vital signs and report concerns to medical professionals.
• Provide hygiene support to reduce infection risks.
• Assist with mobility to prevent falls or further injuries.

Preventing Hospital Readmissions

Hospital readmissions are costly and often avoidable. In-home care reduces this risk by:

• Monitoring Health Conditions: Regular check-ins and assessments help catch issues early.
• Assisting with Follow-Up Appointments: Ensuring patients attend doctor visits and follow care plans.
• Nutritional Support: Preparing meals that align with dietary guidelines.
• Encouraging Physical Activity: Helping patients regain strength and independence safely.

Real-Life Example: A Successful Transition with In-Home Care

Mr. Johnson is a Stroke survivor. After 3 weeks of Hospital and Inpatient Rehab, he was being moved back home where he lives alone. He was now semi-paralyzed (“hemiplegic”) on his upper left side, and could walk using his walker but was afraid to walk more than a few steps. He found it difficult to converse beyond a few words and his speech was partially slurred. He found it difficult to hold a spoon (fine motor skills were impacted). 

His daughter who lives in Houston was there to help him with the initial transition, but she could see that he would face difficulties managing his recovery on his own. With the help of an in-home care aide:

• They ensured proper diet across 3 meals, and medication adherence across a combination of eleven daily meds.
• Fall risk was managed carefully and he was always with someone during the waking hours – a professional caregiver, or a neighbor. 
• Physical therapy sessions were conducted safely at home, slowly and steadily aiding his mobility in addition to muscle strengthening with higher protein and lean meat intake
• Emotional support from his caregiver reduced his anxiety and boosted his confidence and ability to be comfortable with ambulation and a new normal with limited functionality.  In spite of significant speech slur and slower improvement in fine motor skills, he was for example,able to help load Laundry but couldn’t do much in the kitchen.   

Typically, about 25% of ischemic stroke patients end up being readmitted within 30 days of their initial discharge. Thanks to professional in-home care, Mr. Johnson was not one of them. He avoided any major complications, or readmissions and regained partial independence.

Conclusion

The transition from hospital to home is a crucial phase in recovery that requires proper planning and support. In-home care offers personalized solutions to ensure safety, comfort, and effective healing. By choosing in-home care, families can provide their loved ones with the best possible chance at a full recovery while reducing stress and preventing readmissions.

If you or a loved one are navigating the transition from hospital to home, Care Mountain Home Health Care is here to help. Our dedicated team provides exceptional in-home care services tailored to meet your unique needs. Contact us today for more information or to schedule a consultation.