Getting the Care You Need at Home

Before going home after a hospital stay, you will get discharge instructions

from a nurse or other health professional. Understanding these instructions

is important to prevent you from having to return to the hospital. If you

have questions about the care you need, be sure to ask. You might invite

a friend or family member to take notes and ask questions, too. 1

Depending on your conditions, you may need to go to follow-up medical

visits or get tests or therapy. You may need to arrange for home care services

or medical equipment. Finding someone to help you with wound care,

bathing, shopping, or other tasks may also be necessary. 1,2

It is best to start planning for your return home soon after you are admitted

to the hospital. You, your doctor, nurse, and social worker can work together

to create a discharge plan that works for you and your family. 2

Types of Services You May Need

Here's a list of common services that people often need after a hospital stay. Health-related services may be covered by your insurance. 3

Follow-Up Medical Care: Find out what follow-up care you will need after your hospital stay.

When will you need to see your regular doctor or surgeon? Remember to tell your doctor about your hospital stay. 1

Will you need any follow-up treatments? What about blood tests and imaging tests? 1,4

Ask the hospital nurse or other staff person to make follow-up appointments for you. Pick dates and times that work best for you. 1

Getting regular check-ups after a hospital stay can help you stay healthy. Your doctor can catch and address health problems early. This can help you avoid a return to the hospital. 4

Home Health Care: Home care providers (or agencies) assist people when they need help at home. They offer two types of services 5 :

Medical care, such as:
Nursing services, which may include:
Changing bandages
Educating you about your condition
Physical therapy
Assistance with medicines
Nonmedical services, including:
Assistance with household tasks, such as cleaning and cooking
Help with bathing and other personal care
Delivery of medical equipment and supplies, such as a walker or oxygen tank

Therapy: To help you recover, you may need therapy. This might include 1,6,7 :

Physical therapy: To help you improve your ability to move and function
Occupational therapy: To help you perform daily tasks, such as dressing or eating
Speech therapy: For help with speech and communication problems

Therapy is often provided at outpatient centers. Some home health providers may also provide therapy. 1,5

Getting the Care You Need at Home

Care Management: Care managers (or case managers) often have a background in nursing, social work, or a related health field. They begin by assessing your situation. Then they work with you, your doctor, and your caregiver to develop a care plan that meets your needs. They can also help arrange services you may need, from home care to transportation.

You may be assigned to a care manager by the hospital, your doctor, your health plan, or another organization. This shouldn't cost you anything extra. You can also hire a care manager privately, and pay for their services out of pocket. 5,8

Transportation: Transportation can become a big concern after being in the hospital. You may find that you need a ride to the doctor or pharmacy. Consider looking into some of the following options, which may be available for free or at a low cost depending on where you live. Some of these may be covered by your health insurance 9 :

Buses, trains, and other public transit
Paratransit, or accessible public transportation for people who meet criteria under the Americans with Disabilities Act
Taxis and ride-sharing services
Non-emergency medical transportation to doctor appointments
Community programs that enlist volunteers to provide rides

Social Support: A strong social network made up of friends, family, and peers can help you through times of illness and stress. Social isolation and loneliness are linked to a higher risk of mental health issues, cardiovascular (heart and blood vessel) problems, and other health conditions. So take the time to phone family, invite a friend for coffee, or talk with a neighbor. 11 The following services and groups may also help:

Adult day centers are good options if you shouldn't be alone at home during the day and a family member or caregiver is away. The centers offer activities and some provide health services. 5
Support groups give you the opportunity to share experiences, feelings, and coping strategies. A support group also lets you interact with people who can relate to what you are going through. 10
Social networking websites can help you stay in touch with friends and family. Many sites exist for people going through stressful times. 11 However, be careful when choosing online groups to participate in. Some of the information shared may not be true. Also beware of people who are trying to prey on individuals or trying to get them to buy products. 10

Getting the Care You Need at Home

Food Programs: Will you have trouble shopping for or making your own food? Home-delivered meals may be available through programs like Meals on Wheels. A small fee may be charged. You might also look into meals served at churches, community centers, senior centers, day programs, and other local organizations. This can give you a chance to get out of the house and talk with other people while enjoying a meal. 5

Language Help: It can be hard to understand your discharge instructions if you don't speak English or only speak a little English. When talking with your doctor or other health professional, ask for an interpreter. The interpreter helps ensure that you and the health professional understand each other. You can also request written materials in the language you speak. 12

Getting the Care You Need at Home

Where to Find Community Services

If you need help finding or getting information about services that you need, here are some places to start:

Your doctor, care (case) manager, social worker, and other members of your health care team 13
Social service agencies, such as United Way, Jewish Family Services, or Catholic Charities 5
Your local Area Agency on Aging 5

Important Tip

Dial 211 to be referred to health and social services you may need. 211 covers all 50 states, as well as Washington, D.C., and Puerto Rico.

Questions to Ask

When seeking community services, ask questions such as the following 13 :

How do I apply for this service? What are the steps?
What are the eligibility requirements for this service?
Where else might I find help? Can you give me some suggestions?

You will be able to talk to someone who can tell you about the resources available in your community, such as the following 14 :

Medical and mental health resources
Food banks and community meals
Adult day care and respite services for caregivers
Language translation and interpretation for people who do not speak English
Transportation

References

The Joint Commission. SpeakUp: avoid a return trip to the hospital. Published November 2015. Accessed March 21, 2021. https://www.jointcommission.org/-/media/tjc/documents/resources/speakup/speak-ups/avoid-a-return-trip-to-the-hospital/speak_up_transitions_of_care_infographic.pdf 1.
United Hospital Fund. Hospital-to-home discharge guide. Published 2014. Accessed March 21, 2021. https://www.nextstepincare.org/uploads/File/Guides/Hospital/Hospital_to_Home_Guide/Hospital_to_ Home.pdf 2.
Mercer M. Can you afford a home-care worker? AARP. Updated November 4, 2019. Accessed March 21, 2021. https://www.aarp.org/caregiving/financial-legal/info-2017/ afford-a-homecare-worker.html 3.
Heath S. Patient engagement strategies for post-discharge follow-up care. PatientEngagementHIT. Accessed March 21, 2021. https://patientengagementhit.com/features/patient-engagement-strategies-for-postdischarge-follow-up-care# 4.
Family Caregiver Alliance. Caregiving at home: a guide to community resources. Published 2017. Accessed March 21, 2021. https://www.caregiver.org/caregiving-home-guide-community-resources 5.
Seladi-Schulman J. Occupational therapy vs. physical therapy: what to know. Healthline. Published March 11, 2020. Accessed March 21, 2021. https://www.healthline.com/health/ occupational-therapy-vs-physical-therapy#which-to-choose 6.
Santos-Longhurst A. What is speech therapy? Healthline. Published May 9, 2019. Accessed March 21, 2021. https://www.healthline.com/health/speech-therapy#duration 7.
Ivey AG. How a medical case manager can help you save money. GoodRx. Published February 21, 2020. Accessed March 21, 2021. https://www.goodrx.com/blog/medical-casemanagers-save-money/ 8.
AARP. Transportation: what caregivers need to know. Published January 17, 2020. Accessed March 21, 2021. https://www.aarp.org/caregiving/home-care/info-2020/transportation-services.html 9.
Mayo Clinic. Support groups: make connections, get help. Published August 29, 2020. Accessed March 21, 2021. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/ support-groups/art-20044655 10.
Mayo Clinic. Social support: tap this tool to beat stress. Published August 29, 2020. Accessed March 21, 2021. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/ social-support/art-20044445 11.
American Academy of Family Physicians. Do I need an interpreter? Updated March 25, 2020. Accessed March 21, 2021. https://familydoctor.org/do-i-need-an-interpreter/ 12.
National Cancer Institute. Support tips. Accessed March 21, 2021. https:// supportorgs.cancer.gov/tips.aspx 13.
Federal Communications Commission. Dial 211 for essential community services. Updated December 31, 2019. Accessed March 21, 2021. https://www.fcc.gov/consumers/guides/dial-211-essential-community-services 14.