Spending time in the hospital, acute rehab, or a nursing home following an injury, illness, or new diagnosis can come with a lot of unexpected changes. The transition from around-the-clock care to being back in your own home can bring physical and emotional challenges. Whether you or a loved one is going from the hospital or rehab back to their own home, independent living, or another setting, you need to be prepared. It can also be stressful for caregivers who wonder how the person will manage and care for themselves once home.
As a nurse who has overseen countless transitions from healthcare settings to home, it is not always easy. Often, new skills need to be learned, and additional support is needed, so having a plan in place can help reduce stress for everyone involved. I am going to share some of the main things I look at and want to help patients and families address for a smoother transition.
What to Plan For
Patients often imagine the moment they will get to return home. They want life to return to “normal” and for them to regain some independence and their routine. Unfortunately, this drive to get home causes people to forget that caring for themselves may be harder or different after their hospital stay. They may be picturing that moment when they walk through the front door, sit in their favorite chair, and hear the silence after days or weeks of being interrupted by beeping machines. But what happens next? How are they going to manage their medications? Do they need help going to the restroom? Can they prepare their own food?
As an experienced geriatric nurse, these are the things I’m thinking about and trying to help people plan for when going through this transition. People are often in such a rush to get home that they end up being unprepared and back in the hospital. Making sure they can manage on their own and that supports are in place before leaving can lead to a smoother, more successful transition.
It can be helpful to use a real-life scenario to think through what a hospital-to-home transition will look and feel like. Then you can make and adjust a plan based on the person and why they were hospitalized.
In this scenario, a patient of mine is recovering from a hip fracture resulting in a hip replacement and has spent around 6 weeks in short-term rehab. They are planning to return home, where they live alone. As an experienced geriatric nurse, I am looking at the whole picture to ensure they are safe and can care for themselves. This patient was independently caring for themself before their injury.
While in rehab, they have received assistance with their activities of daily living (ADLs), including dressing, bathing, eating, toileting, and functional mobility. While they have regained some strength and can complete most tasks independently, they tire more easily and are used to having a helping hand whenever needed. They also experienced occasional bladder leaks before their injury and were able to manage with liners. Since their injury, they are now using a walker and are experiencing more frequent episodes of incontinence due to it taking longer to reach the restroom. Furthermore, they are leaving with new medications and will need to continue outpatient physical therapy. While eager to return home, these patients typically express some fear or anxiety around their ability to care for themselves and are often at an increased risk for future falls/injury and self-neglect due to deconditioning.
Feeling overwhelmed and fearful are common things people describe when going through this transition. They aren’t sure how they will manage to care for themselves and their house. They often have been relying on friends or family members for support while in rehab, and hesitate to ask for continued or increased support once they go home.
My job, often in partnership with a social worker and rehab team, is to help identify areas where this person will need support once they are home. These are some key areas where having a plan will help to address common challenges faced during these transitions.
Activities of Daily Living (ADLs)
As mentioned above, ADLs are a commonly used term in healthcare to describe the activities individuals need to complete each day to care for themselves. This includes bathing, dressing, personal hygiene, toileting, and eating. It is important to understand from the rehab team if the person going home will need adaptive equipment. This can often include a walker, a cane, a shower chair, a wheelchair, or grab bars. These items can sometimes be ordered and covered by insurance, but will vary widely. Any necessary equipment or home modifications need to be available before the person goes home.
I always recommend adapting the home environment as closely as possible to what worked in the hospital or rehab, rather than going right back to old habits. This can look like completing hygiene tasks while seated in a wheelchair or using a walker, even indoors, to conserve energy while dressing or preparing food in the kitchen.
Managing Medications
Medication management is an important part of returning home. I like to assess each patient’s ability to manage them safely. This includes having them tell me which medications they take, how much, and why. I make sure they understand any safety steps, such as taking their blood pressure or pulse before taking the medication. If they are using injectable medications, it includes watching them give it or watching the family member give it to make sure they know what to do. I often see patients return home and then immediately have issues with medication compliance because they either lack the skills or knowledge to safely and correctly take them.
Options for medication management include having the individual, a family member, or home health nurse (if deemed necessary by your provider and/or insurance) fill a weekly mediset (a box with different slots for medications at designated times of day) or have medications arrive in pill packs directly from the pharmacy. If choosing a mediset option, I recommend something like this, as they are designed to open easily, which is helpful for people with limited dexterity (due to conditions such as Parkinson’s or arthritis). Finding a sustainable solution to ensure medication refills are obtained and that you remember to take them is critical.
Managing Incontinence
When thinking about managing incontinence at home, I recommend speaking with the nurse or aide who has been helping you and writing down the names and sizes of incontinence products that have worked for you. Order or have a friend or family member order supplies so they are ready at your home when you arrive. Many incontinence manufacturers sell products on Amazon or other online retailers, where you can set up automatic deliveries so you don’t have to worry about running out. Options such as LivDry have large product catalogs, which can help you find the right product and fit without spending time at the store. I recommend not buying too many of one product until you know it works for you. It can help to try a few different styles and consult an incontinence product guide to ensure sizing is right before placing a larger order.
One of the details I see people struggle with around incontinence is their bathroom setup and managing the extra trash. I always recommend storing your supplies close to the toilet where they are within reach. Having to try and find products in a hurry or reaching too far for them mid-change can cause falls or injury. On the same note, you will want to have a trash can (one with a sealing lid, like a diaper can) nearby to contain disposable items and reduce odors.
Overnight incontinence support can also look different, as you won’t have someone available to help with overnight changes. You may need a more absorbent product and bed pads in case of overflow. Having reliable adult diaper protection can reduce the number of leaks and linen changes you have to do. A great starting point is a waterproof mattress cover, washable or disposable bed pads, and your choice of absorbent pull-up underwear or brief, depending on the amount and frequency of incontinence you experienced in the hospital or rehab setting.
Transportation
After a hospitalization or rehab stay, your ability to drive may have changed. It may not be safe to do so if you are still taking pain medication or recovering from an injury or surgery. I always want to make sure patients have reliable transportation not only for medical appointments but also to get groceries, medications, and other necessary supplies. If they do not have a family member or friend or live in a facility that provides transportation, there are other options, such as ride shares or local transportation, which will vary by where you live.
Social and Emotional Impacts
Unfortunately, it is common for patients to experience a disconnect between the care they receive in a structured care setting and the care they receive at home. Based on current research, older adults specifically report social isolation, issues with support from their community, and experiencing new or worsening depression and anxiety.
In my experience, addressing the social and emotional concerns can be difficult. I see patients tend to self-isolate at home, reduce their activities, and feel they are burdening family and friends, so they do not seek help. It is essential to ensure supports are in place, such as a rotating schedule of visitors, routine visits to a local senior center, and follow-up visits with a behavioral health provider when indicated for anxiety and depression.
Being Prepared to Go Home After the Hospital
Knowing the areas where people can face challenges when returning home after the hospital or rehab can help you develop a plan. In my years of work, I too often see people return home in a rush to find a sense of normalcy, only to be readmitted days or weeks later. Slowing down and taking the time to return home safely, with a plan and support in place, will go a long way in recovery.
