One in five Medicare patients is readmitted to the hospital within 30 days of discharge. Most of these readmissions are preventable. They happen because the transition from hospital to home — one of the most medically complex periods of a senior's life — often doesn't receive adequate support.
Discharge can feel abrupt. The hospital is ready to send your parent home, but the home isn't ready to receive them. Medications have changed, functional abilities have changed, and the environment that felt safe before the hospitalization may now be inadequate.
This guide is for families who want to get the transition right.
Before the Patient Leaves the Hospital
Request a Discharge Planning Meeting
Every hospital patient has the right to discharge planning. Ask to meet with the hospital's social worker or discharge planner before your parent leaves. This meeting should address: what happened, what care they'll need at home, what equipment is needed, what follow-up appointments are required, and what warning signs should prompt a call to the doctor or a return to the ER.
Understand Every Medication Change
Medication errors during the transition period are a leading cause of readmission. Before leaving the hospital:
- Get a complete list of all current medications, including new ones and discontinued ones
- Ask the discharge nurse to walk through each medication: what it's for, the dose, when to take it, and any side effects to watch for
- Confirm what the patient was taking before hospitalization and whether any of those medications have been stopped or changed
- Ask about interactions with foods or other medications
- Fill all prescriptions before arriving home — or arrange for delivery that day
Ask About Home Health or Therapy Services
If your parent meets Medicare criteria, they may qualify for skilled home health services — including nursing visits, physical therapy, occupational therapy, and speech therapy — at home, at no cost to them under Medicare Part A.
These services must be ordered by the physician and provided by a Medicare-certified home health agency. Ask the discharge planner if home health has been ordered, and if not, whether it is appropriate to request.
Prepare the Home Before Arrival
- Clear a path from the car door to the bedroom and bathroom
- Move the bed or sleeping area to the ground floor if stairs are a concern
- Set up a bedside commode if getting to the bathroom quickly will be difficult
- Install grab bars if not already present (see our fall prevention guide)
- Stock the refrigerator with easy-to-eat, nutritious foods
- Set up a medication management system: a pill organizer sorted by day and time, or a dispenser with alarms
- Have a notebook by the bed to track symptoms, vital signs, and questions for the doctor
The First 72 Hours at Home
The first three days are highest risk. If possible, have a family member present or arrange for a professional caregiver during this period.
- Take all medications as prescribed and on schedule
- Monitor for warning signs specific to the patient's condition (ask the hospital for a written list)
- Check the surgical site or wound (if applicable) for signs of infection: redness, warmth, swelling, discharge, or fever
- Monitor fluid intake — dehydration is extremely common post-discharge
- Attend all scheduled follow-up appointments, especially the 7-day physician visit if ordered
- Don't hesitate to call the physician's office with any concern — they expect post-discharge calls
Warning Signs That Warrant an Immediate Call
- Fever above 101°F (38.3°C)
- Chest pain or difficulty breathing
- Significant confusion or sudden change in mental status
- Uncontrolled pain
- Wound that looks infected or is not healing
- Inability to keep medications or fluids down
- A fall, even if no injury seems apparent
- Any symptom the hospital told you specifically to watch for
Love Thy Neighbor Senior Care specializes in post-hospital transitions. Our skilled nursing team provides wound care, medication management, and vital sign monitoring. Our personal care aides assist with bathing, dressing, and mobility during recovery. Call us at (402) 205-3016 — we can often arrange care within 24 hours.
Longer-Term: Preventing Readmission
Most preventable readmissions happen because a warning sign was missed, a follow-up appointment was skipped, or a medication problem went uncaught. Having consistent professional oversight — even just a few hours per day — dramatically reduces this risk.
As your parent recovers, their care needs will change. What they need in week one may be very different from what they need in week six. Stay in communication with the care team and adjust the plan as recovery progresses.