6 Steps for a Successful Care Transition from a Hospital

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Trips to the hospital can be a disrupting experience for aging adults. For assisted living residents, hospitalization may lead to a loss of independence upon return to the community. Fortunately, assisted living staff are committed to safely reducing repeat hospitalizations for residents.

Assisted living staff want the transition from a hospital to a community to be as smooth as possible so your loved one is less likely to end up back in the hospital. 

Here are six steps you can take to help make a successful care transition from a hospital to an assisted living community.

1. Ask for post-care instructions

Before leaving the hospital, ask your doctor to provide written post-care instructions. Make sure these instructions are simple enough for you and your loved ones to read and understand.

It may also be helpful to set up an appointment with your hospital nurse before you leave. You can use that time to review discharge information with your loved ones and ask questions. Then, bring these instructions when you return to your assisted living community.

2. Know your health status

Ask hospital staff about your current health condition as much as possible before leaving. Make sure you are aware of potential symptoms you may face and how to respond to them. For example, it may be common to experience problems like indigestion or nausea, depending on your condition. The hospital can work with you and the assisted living staff to understand how they may be able to treat these symptoms instead of admitting you to the hospital again.

3. Make a care plan

Knowing the plan for your care after leaving a hospital can help you and your loved ones feel more prepared. Discuss the transition with hospital staff, and decide how the assisted living staff will be involved in your care. Questions to consider include:

  • How often will hospital staff and assisted living staff communicate about your needs?
  • What activities – like bathing or dressing – will you need assistance with when you return to the community?
  • Will your family or other loved ones help with care?

When you understand your care plan, you and your loved ones can avoid confusion and communicate more effectively with your nursing staff.

4. Discuss medications

Ask your care providers at the hospital for complete information about all of your medications. Using medicine incorrectly increases your risk of overmedication. Know the name, dose and reason for each medication before leaving the hospital. Use this checklist to prevent overmedication.

You should discuss any medication information with the staff at your assisted living community. They can help you understand medication instructions and avoid preventable issues.

5. Understand follow-up information

Discuss next steps for your care with hospital staff. Ask if you will have any follow-up appointments with doctors or specialists. Then, share this information with your assisted living community’s staff so that they know what to anticipate.

It's also important to be aware of changes to your care routine. After a hospital stay, you may need to use new equipment – like a wheelchair or walker – or make adjustments to your daily schedule. Your community’s staff can help you better understand and successfully adapt to these changes.

6.  Review advance directives

An advance directive is a document that outlines your preferences for care. This document can help you communicate your wishes to loved ones and avoid confusion. Make sure you:

  • Review these important documents with your loved ones before leaving the hospital.
  • Confirm that the document still accurately reflects your preferences for treatment.
  • Provide up-to-date copies to the assisted living community.

If you don't have these documents or if you need to make changes, talk to hospital staff.

View this checklist for more information on how to prepare for a hospital discharge.