Home Care’s Role in Older Adults’ Post-Acute Transition

by Lakelyn Hogan on Mar 1, 2019

Home Instead Caregiver pushing Senior in Wheelchair.jpgWhen older patients return home from the hospital, it’s the little things that often get overlooked. The older adult is sent home with detailed discharge plans containing important information and instructions for the patient and their family members. However, families may not anticipate the additional tasks that will be required to help make their aging loved one’s transition home a smooth experience. Professional home care services are often an overlooked service that can aid in this transition and help families with these overwhelming responsibilities.

When considering the assistance an older adult may need after being hospitalized, there are four key activity areas that may require family caregivers to assume more responsibility, time and effort than normal day-to-day activities. Many of these activities may also be delegated to home care’s trained professionals or home healthcare services.

1. Healthcare Tasks

  • Review discharge plan or care plan
  • Change dressings
  • Monitor vital signs
  • Operate or adjust medical equipment
  • Assist with personal hygiene
  • Arrange for follow-up care
  • Maintain a schedule of healthcare visits and appointments

2. Medication Management

  • Order and pick up prescriptions and refills
  • Understand all medication labels, instructions and expiration dates
  • Administer the correct medication at the right time
  • Monitor for side effects
  • Store medications properly and safely
  • Maintain medication schedule
  • Dispose of medications
  • Use a medication tracking system to record all medications

3. Household Management

  • Ensure a safe environment by completing frequent home safety checks
  • Check the fridge for outdated and spoiled foods before discharge is complete
  • Prepare special meals such as low-sodium or liquid-only diets
  • Shop for what is needed upon returning home, including special foods and new supplies
  • Manage schedule and communications with visiting healthcare and home care professionals
  • Arrange for deliveries of medical supplies and equipment

4. Family Communications

  • Prepare and maintain emergency and medical contact lists
  • Communicate frequently with family members and healthcare team
  • Pay medical and other bills
  • Assist with mail
  • Provide instructions and training to other family members and friends
  • Assemble and store important documents, such as those typically listed in a senior emergency kit:
    • Advance Directive
    • Living Will/Standard Will

Family members are often overcome by the wide range of caregiving responsibilities listed above. This may be due to the lack of time in their busy schedules, a lack of confidence in their caregiving skills or the inability to provide for these needs. This can unfortunately result in missed follow-up appointments, medication mismanagement and readmissions to the hospital.

Readmissions are not only distressing for the older patient and their families, they are also an undesirable outcome for the health system. According to data from the Medicare Payment Advisory Commission, nearly one in five seniors discharged from the hospital will be readmitted within the first 30 days due to preventable factors. Professional home care services can help to identify these preventable factors and reduce the risk for readmissions.

What is Professional Home Care?

Professional home care is a type of service that can span the entire senior care spectrum. As you can see in the graphic below (courtesy of Home Instead Senior Care), home care can support an individual from independence through to higher levels of care and support. With customizable care plans, services can be tailored to assist a few hours a week up to 24/7 during the transitional period and beyond. Home care assists with a range of services from personal care and activities of daily living (ADLs) to medication management, home helper activities, transportation and Alzheimer’s care.  No matter if the individual is transitioning to a residential home or to a care community, the flexibility of home care allows for services to be provided in variety of settings.

HomeInsteadSeniorCareSpectrumThe overall goal of home care during a transition from the hospital is to increase positive outcomes for older patients and their families. A recent study conducted by Home Instead, Inc. found many benefits of home care services, including:

  • Increased amount of care
  • Fewer visits to the doctor
  • Improved quality of life for both seniors and their family caregivers
  • Positive economic impact, including reduced medical care costs
  • Shortened hospital stays
  • Reduced hospital admissions
  • Extending care along the continuum

Including Home Care in the Discharge Plan

Including home care early in the discharge planning discussion can provide a better understanding of the support that can be offered.  Home care can be especially helpful in cases where additional one-on-one home support can help increase the likelihood a patient makes a successful recovery without a return trip to the hospital. Below are some areas that home care can make a significant impact during the transition home:

  • Discharge coordination and execution– working with a senior patient's hospital staff to help create a plan of care.
  • Medication management– assistance organizing and tracking medications to make sure they're taken as directed.
  • Follow-up physician visit assistance– helping seniors keep track of and attend all necessary follow-up medical appointments.
  • Nutrition management–providing assistance with food shopping and meal preparation to help ensure the senior maintains a healthy diet.
  • Warning sign monitoring and notification– watching for warning signs and taking appropriate action.
  • Record-keeping– keeping track of the senior's recovery progress to share with his or her physicians.

By partnering with home care providers in your community, they can become a vital transitional care resources for healthcare professionals. Home care can also be a source of support to the older patient and their family members to ease the transition home. In the end, it is those little things in the transition that can make all of the difference and home care can ensure the little things get the time and attention they deserve.

For more information about readmission reduction and transitional care services, visit learn more about home care services and to find a local home care provider visit

How much can your organization save with automated discharge technology? Calculate your ROI.

Meet the Author

Lakelyn Hogan is Gerontologist and Caregiver Advocate for Home Instead Senior Care. Lakelyn works to educate professionals, families and communities on issues older adults face. Lakelyn is a doctoral candidate at the University of Nebraska – Omaha where she is studying Social Gerontology. She has a Master of Arts in Social Gerontology and Master’s in Business Administration from UNO. Lakelyn has professional experience in the private and public sectors of senior care services. She has worked on special projects for UNO’s Department of Gerontology and the local Area Agency on Aging. Lakelyn serves as Vice President of the Board of Directors for the Dreamweaver Foundation and is active in the Alzheimer’s Association’s Walk to End Alzheimer’s. Lakelyn has a passion for helping others, especially aging adults and their families.