Post-Hospital Care at Home: A Recovery Guide for Maryland Families

Bringing a loved one home from the hospital should be a relief, but it often feels overwhelming. Proper post-hospital care is crucial for recovery and preventing readmission. This guide will help you navigate the transition from hospital to home successfully.

Why Post-Hospital Care Matters

The Statistics:

• 20% of Medicare patients are readmitted within 30 days
• 50% of readmissions are preventable
• Proper home care reduces readmission risk by 25-50%

Common Reasons for Readmission:

• Medication errors or non-compliance
• Missed follow-up appointments
• Inadequate wound care
• Falls or injuries
• Infection
• Worsening of chronic conditions
• Lack of support at home

Before Hospital Discharge

Questions to Ask the Discharge Team:

About Medications:

1. What medications should be taken? When and how?
2. Which medications were stopped or changed?
3. What are potential side effects?
4. Can medications be taken together?
5. Should medications be taken with food?

About Activity Restrictions:

1. What activities are safe?
2. When can they shower/bathe?
3. Are there lifting restrictions?
4. When can they drive?
5. When can they return to normal activities?

About Diet:

1. Are there dietary restrictions?
2. Should they avoid certain foods?
3. How much fluid should they drink?
4. Are there special nutritional needs?

About Wound Care:

1. How should wounds be cleaned?
2. How often should dressings be changed?
3. What signs of infection should we watch for?
4. When should stitches/staples be removed?

About Follow-Up:

1. When should they see their primary doctor?
2. Are specialist appointments needed?
3. What symptoms require immediate medical attention?
4. Who should we call with questions?

Get Everything in Writing:

• Discharge summary
• Medication list with instructions
• Follow-up appointment schedule
• Warning signs to watch for
• Emergency contact numbers

Preparing the Home

Safety Modifications:

Bedroom:

• Hospital bed (if needed)
• Bedside commode
• Call bell or phone within reach
• Good lighting
• Clear path to bathroom

Bathroom:

• Grab bars installed
• Shower chair or bench
• Non-slip mats
• Raised toilet seat
• Handheld showerhead

Throughout Home:

• Remove tripping hazards (rugs, cords)
• Improve lighting
• Install handrails on stairs
• Keep frequently used items within easy reach
• Clear pathways for walkers/wheelchairs

Medical Supplies Needed:

• Medications (filled before discharge)
• Thermometer
• Blood pressure monitor (if needed)
• Glucose monitor (for diabetics)
• Wound care supplies
• Medical equipment (oxygen, nebulizer, etc.)
• Incontinence supplies (if needed)

First Week at Home

Daily Monitoring:

Vital Signs:

• Temperature (watch for fever)
• Blood pressure (if instructed)
• Heart rate
• Blood sugar (for diabetics)
• Weight (for heart failure patients)
• Oxygen levels (if on oxygen)

Physical Assessment:

• Wound healing progress
• Pain levels
• Mobility and strength
• Appetite and fluid intake
• Bowel and bladder function
• Mental clarity

Medication Management:

• Use pill organizers
• Set alarms for medication times
• Keep medication log
• Watch for side effects
• Never skip doses

Warning Signs Requiring Immediate Medical Attention:

🚨 Call 911 if:

• Chest pain or pressure
• Difficulty breathing
• Severe bleeding
• Loss of consciousness
• Stroke symptoms (face drooping, arm weakness, speech difficulty)
• Severe allergic reaction

☎️ Call Doctor if:

• Fever over 100.4°F
• Increased pain not relieved by medication
• Wound showing signs of infection (redness, swelling, drainage, odor)
• Nausea/vomiting preventing medication or food intake
• Confusion or behavior changes
• Swelling in legs or ankles
• Shortness of breath

Common Post-Hospital Challenges

1. Medication Confusion

Problem: Multiple new medications, complex schedules

Solutions:

• Use pill organizers
• Create medication schedule chart
• Set phone alarms
• Ask pharmacist to review all medications
• Consider professional medication management

2. Mobility Issues

Problem: Weakness, balance problems, fear of falling

Solutions:

• Physical therapy (if ordered)
• Use assistive devices (walker, cane)
• Supervised walking practice
• Strength-building exercises
• Professional caregiver assistance

3. Wound Care

Problem: Complex dressing changes, infection risk

Solutions:

• Follow instructions exactly
• Keep wounds clean and dry
• Watch for infection signs
• Take photos to track healing
• Consider home health nurse visits

4. Nutrition and Appetite

Problem: Poor appetite, dietary restrictions

Solutions:

• Offer small, frequent meals
• Make favorite foods (within restrictions)
• Ensure adequate hydration
• Consider nutritional supplements
• Professional meal preparation help

5. Emotional Adjustment

Problem: Depression, anxiety, frustration

Solutions:

• Acknowledge feelings
• Maintain social connections
• Set small, achievable goals
• Celebrate progress
• Consider counseling if needed

Creating a Care Schedule

Daily Routine:

Morning (7-9 AM):

• Morning medications
• Vital signs check
• Personal care (bathing, dressing)
• Breakfast
• Light activity/exercises

Midday (12-2 PM):

• Lunch
• Midday medications
• Rest period
• Light activity

Afternoon (3-5 PM):

• Snack
• Physical therapy exercises
• Social activity
• Wound care (if needed)

Evening (6-8 PM):

• Dinner
• Evening medications
• Personal care
• Relaxation

Night (9-11 PM):

• Bedtime medications
• Final vital signs check
• Ensure call bell/phone nearby
• Night light on

Follow-Up Appointments

Schedule Immediately:

• Primary care doctor (within 7-14 days)
• Specialists (as recommended)
• Physical therapy
• Home health nurse visits

Before Each Appointment:

• Write down questions
• List any concerns or symptoms
• Bring medication list
• Bring discharge paperwork
• Bring someone to take notes

When to Consider Professional Help

Post-hospital care is demanding. Consider professional home care if:

• Complex medical needs (wound care, IV medications, etc.)
• 24/7 supervision required
• Family caregivers are overwhelmed
• Patient lives alone
• High risk of readmission
• Multiple medications need management
• Physical therapy exercises need supervision
• Mobility assistance required

How Kindred Caregivers Supports Post-Hospital Recovery

We specialize in post-hospital care to ensure safe, successful recovery:

Our Post-Hospital Services:

✅ RN-Led Care Plans - Registered nurse creates personalized recovery plan ✅ Medication Management - Ensure medications taken correctly and on time ✅ Wound Care - Proper dressing changes and infection monitoring ✅ Mobility Assistance - Safe transfers, walking support, fall prevention ✅ Transportation - Rides to follow-up appointments ✅ Meal Preparation - Nutritious meals following dietary restrictions ✅ Personal Care - Bathing, dressing, grooming assistance ✅ Vital Signs Monitoring - Track temperature, blood pressure, etc. ✅ Family Communication - Regular updates on progress ✅ 24/7 Availability - Care available around the clock if needed

We Can Start Care Immediately:

• Same-day service available
• 30-minute response time
• Flexible scheduling (a few hours to 24/7)
• Short-term or long-term care

Preventing Hospital Readmission

The Five Keys:

1. Take Medications Correctly

   • Follow schedule exactly
   • Don't skip doses
   • Report side effects

2. Attend All Follow-Up Appointments

   • Schedule before leaving hospital
   • Don't cancel or postpone
   • Bring questions and concerns

3. Watch for Warning Signs

   • Know what symptoms to report
   • Don't ignore changes
   • Call doctor with concerns

4. Follow Activity Restrictions

   • Don't do too much too soon
   • Gradually increase activity
   • Use assistive devices

5. Get Help When Needed

   • Don't try to do everything alone
   • Accept help from family and professionals
   • Prioritize recovery

The Bottom Line

Successful post-hospital recovery requires:

• Clear discharge instructions
• Safe home environment
• Medication compliance
• Follow-up appointments
• Monitoring for complications
• Adequate support

With proper planning and support, most people recover successfully at home and avoid readmission.

Call Kindred Caregivers at 443-386-8466 if your loved one is being discharged from the hospital. We can start care immediately to support a safe, successful recovery. We serve Baltimore, Howard, Carroll, and Frederick Counties.

Don't wait until problems arise—let us help from day one to ensure the best possible outcome.