Transition from Hospital to Home


It is 8:30am, patient X, who we will call Joe has just received word that he will be discharged from the hospital today. He has been there for 5 days due to Pneumonia. The nurse hurries in and out trying to get all of his paperwork filled out and sent to the doctor and specialist for sign off. 11am rolls around. The doctor walks in and gives Joe his plan of care. “Hi Joe, here is your plan of care. Any questions?” “No doc, thank you.” “Great, be sure to get plenty of rest when you get home and make sure to take your medicine.” Once the doctor left the room a nurse came in to get Joe ready for his taxi ride home. Joe does not have relatives in the area and he no longer drives. His transition from hospital to home will be done on his own.

He finally gets home and realizes he did not really discuss his medication plan, hopefully it will be written down on one of the papers given to him by the doctor back at the hospital. Joe sifts through them but can’t quite fund what he needs. He makes a mental note to call his doctor   later. Unfortunately, he doesn’t remember later. Joe goes to the refrigerator to get something to eat, everything has gone bad. He will have to place an online grocery order, but that food won’t arrive until the next day.

This story could go on, but we will stop there. While the transition from hospital to home may be a breeze for some, many seniors find themselves in Joe’s position. No one to help him          understand his discharge instructions, no one to help him get home and no one to get his house in order following his long stay in the hospital. This recipe unfortunately often leads to an        unplanned readmission to the hospital because the understanding of the situation and the       isolated environment make it very difficult to navigate oneself back to health. Several studies have been conducted suggesting the indisputable need and benefit of a “transition coach” or “transition caregiver.” It not only helps the patient from backsliding but it may also help the     hospital by reducing unplanned readmission and lowering costly fines.

Georgetown Home Care has the resources and amazing caregivers to make that smooth       transition happen for you. Please contact us for more information.

-Georgetown Home Care