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Providing a website featuring publications in the nature of blogs, articles, and brochures in the fields of home health care services, non-medical personal care assistance with activities of daily living, and disease maintenance.

Avoiding Re-Hospitalization with In-Home Care

Some hospitalizations are planned—perhaps for a joint replacement, coronary artery bypass surgery, or gallbladder removal. Other hospital admissions happen after a sudden illness or injury—a hip fracture, acute appendicitis, a stroke, or a heart attack.

Whether a hospital stay is planned or unexpected, following your post-discharge instructions provides the best chance of a successful recovery, with the fewest complications.

Recovering senior patient with caregiver

According to Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality (AHQR), millions of patients each year are discharged from the hospital, only to end up being readmitted. Clancy says, "Often it’s because patients and caregivers don’t understand what they need to do to take care of themselves or their loved ones after a hospital stay."

This "revolving door" is such a major (and costly) problem for our healthcare system that Medicare has stopped paying hospitals for additional costs that result when certain preventable conditions cause patients to end up back in the hospital. Today, much attention is being paid to reducing hospital re-admission.

Things to know about hospital stays today:

Patients are discharged sooner than ever. You may have heard the term "quicker and sicker." Hospital stays are on the whole much shorter than they used to be. Some patients are discharged to a skilled nursing facility or other care community. Many others return home while they still need help managing their recovery.

"Bed rest" is becoming a thing of the past. Resuming physical activity is now known to promote faster healing. A recent study from the University of Texas Medical Branch at Galveston showed that hospitalized elderly patients who literally "get back on their feet" while still in the hospital can go home sooner. The stakes are high, says researcher Glenn Ostir: "Do patients rebound and do better, or do they wind up in a downward spiral that leads to increased re-hospitalization?" Immobility decreases the chances of a smooth recovery.

Successful recovery depends on compliance with discharge instructions. But the recovery regimen can be challenging and complex. Patients who are in pain, perhaps taking medications that leave them groggy, are in no shape to understand this information. It is recommended—and in many cases required—that the patient be accompanied upon discharge, and have assistance at home.

It's important to have a plan. Patients should discuss aftercare with the healthcare provider or hospital discharge planner before they leave—before their treatment, if that's possible. They should take notes and bring a list of questions. How long is recovery expected to take? What is the best setting for recovery? What are the financial considerations? What kind of care will be needed?

Families may be unavailable or unable to provide the care their loved one needs.  Many family members are called upon to serve as caregivers for recovering patients, but they often feel unprepared. They may lack the physical strength and training to perform unaccustomed care tasks. Changing a dressing and helping a loved one to the toilet are out of the comfort zone for many!

The role of home care

In some cases, patients are discharged to a nursing home or other care community for recovery and rehabilitation. But many patients who might have formerly required institutional care can now be treated in the comfortable and familiar surroundings of their own home. Home health care aides or in-home companions may be part of the solution. In-home caregivers support successful recovery by:

  • Encouraging medication compliance by providing medication reminders, taking the patient to the pharmacy or picking up prescriptions, and reporting any side effects.

  • Providing supervision and an extra measure of confidence as the patient resumes the physician's prescribed activity and exercise plan.

  • Ensuring that the home is a good recovery environment by performing housekeeping tasks that the patient shouldn’t, being watchful for hazards that might cause the patient to fall, and providing reassuring companionship.

  • Assisting patient with the activities of daily living, such as dressing, bathing, eating, transferring from bed to chair, and toileting.

  • Transporting the patient to outpatient follow-up appointments, physical therapy and other outside-the-home activities; and coordinating home visits from physical therapist and other providers.

  • Supporting family caregivers by providing peace of mind when family have time conflicts with jobs and other responsibilities, live at a distance, or have health needs of their own that make it difficult to provide care.

For more and more patients today, in-home care helps assure successful recovery in the comfort of their own homes.

Learn More

The Agency for Healthcare Research and Quality recently released a new resource to help patients prepare for leaving the hospital. Taking Care of Myself: a Guide for When I Leave the Hospital is based on a Boston University Medical Center program whose participants experienced 30% fewer readmissions.

Click here for more information regarding Right at Home's Care Transitions Initiative.


Right at Home is a national organization dedicated to improving the quality of life for those we serve. We fulfill that mission through a dedicated network of locally owned, franchised providers of in-home care services.

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