Transitional Home Care: How Care Aides Can Help Seniors After a Hospital Stay


Hospital stays often cause stress and anxiety for seniors and their family caregivers. After a hospitalization, family members are eager for their loved ones to return home, recover, and resume their normal routines. However, few anticipate the difficulties that can arise when older adults move between care settings.

Fortunately, transitional home care helps ease these transitions from hospital to home.

What is transitional home care?

Transitional care is the care provided for someone moving from one care site to another. When your loved one is discharged from the hospital, they may need immediate services to continue their recovery and prevent rehospitalization. A senior may benefit from transitional home care if they require additional support and supervision upon returning to their previous living situation (or a new one). This is especially important for older adults who live alone or have limited support from informal sources like family and friends.

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Navigating hospital discharges and preventing hospital readmissions

Multifaceted complications can arise from care transitions. This can contribute to what has come to be known as the “revolving door” of hospital readmissions. Research conducted by the Centers for Medicare & Medicaid Services (CMS) says, “Nearly one in five Medicare patients discharged from a hospital — approximately 2.6 million seniors — are readmitted within 30 days, at a cost of over $26 billion every year.

Many readmissions are preventable and can be avoided with:

  • Increased patient and family caregiver education
  • Improved communication
  • Better discharge planning
  • Proper post-hospitalization care

Hospitals, CMS, and the U.S. Department of Health and Human Services (HHS) are working diligently to reduce rehospitalization rates. However, seniors and their caregivers can take steps on their own to prevent readmission as well. Professional transitional home care can play an important supporting role in transitions between care settings.

The benefits of hiring transitional home care

Each patient has specific needs following a surgery or hospital stay. In-home care offers several core services that can facilitate the recovery process, improve quality of life, and help ensure discharge instructions are followed. This added support also alleviates pressure on family caregivers.

Better communication and care coordination

Clear communication is crucial for coordinating care among multiple health care providers and across different settings. Regular communication helps a senior get the care they need in the hospital and after they’ve been discharged.

It’s important for patients and family caregivers to ask specific questions and request explanations of unfamiliar concepts. This will help the entire care team achieve a better understanding of all conditions, treatments, and post-discharge instructions. Caregivers can add a layer of knowledge and experience that can help facilitate the discharge planning process. Professional caregivers can be invaluable when it comes to learning about a client’s health issues, ensuring that treatment is followed, and determining what services and assistance will be necessary to help them resume their normal routines.

Many patients are understandably eager to leave the hospital and return home, but discharge planning is important. Rushing through this process can increase the risk of missing key points, resulting in fragmented instructions for post-acute care.

Improved adherence to discharge instructions

Medications are often changed or added to a senior’s regimen following a hospital stay. A home health aide can make sure these modifications are adhered to once the senior returns home. In-home caregivers can help seniors with:

  • Picking up prescriptions from the pharmacy
  • Medication reminders
  • Keeping an eye out for new and worsening side effects
  • Following discharge orders for bed rest
  • Walking around periodically
  • Performing therapeutic exercises and stretches

Follow-up appointments with an elder’s primary care physician and even specialists are another key part of post-hospital care. A professional care aide can help schedule these appointments, provide transportation to and from visits, and take notes. In-home care providers will incorporate all these directives into a personalized care plan. This plan should be followed by the patient, their professional caregiver(s), and their family members.

Help with personal care and household tasks

Research has shown that hospitalization is associated with declines in functional abilities, and seniors often return to their homes with unmet needs for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). One study found that unmet ADL needs increase the risk of hospital readmission.

A senior’s new or worse functional disabilities and access to supportive resources may not be adequately addressed during the hospital discharge process. Fortunately, in-home care provides valuable support for ADLs and IADLs. Services can include light housekeeping, meal preparation, assistance with bathing, dressing, walking, transfers, and more.

Supervision and companionship

A smooth hospital-to-home transition requires multiple precautions and steps. Hiring an experienced aide provides another level of supervision during this critical time. Extra monitoring can help prevent complications, detect changes in health, and decrease the risk of rehospitalization. This added peace of mind is an undeniable perk for families, especially long-distance caregivers.

Additionally, in-home aides cultivate meaningful relationships with their clients. Loneliness and a lack of engagement are detrimental to a senior’s physical and mental health. This can especially be the case in the wake of a medical setback. Patients may not be able to return to their normal routines immediately following a hospital stay. However, professional caregivers provide social interaction and are skilled at devising activities that fit a senior’s abilities and preferences.

Hiring transitional home care

Home care agencies can help fill the gaps between hospital-to-home care transitions for either short- or long-term periods. Some family caregivers may experience anxiety about hiring someone to help care for their loved one after a hospital stay. However, an extra set of hands and eyes can lessen the risk of a return visit. Depending on the level of care required, medically necessary home health care may be ordered upon discharge. If it isn’t, non-medical home care services can still provide support for the entire family.

Read: Differences Between Home Health Care and Non-Medical Home Care Services

After determining the kind of transitional home care your loved one requires, a selection and interview process can help you find a provider that meets their needs. Delays in proper post-hospital care can increase the likelihood of readmission. Therefore, it’s important to start your search in a timely fashion. Finding the best care for your loved one may take some time and effort. AgingCare’s trained Care Advisors can facilitate this process by connecting you with local home care providers that match your loved one’s needs and budget.

Read: How to Choose a Home Care Agency

Definitions of Transitional Care (
Transitional Care (
Transitional Care: Moving patients from one care setting to another (
The Revolving Door: A Report on U.S. Hospital Readmissions (
Community-based Care Transitions Program (
Final Evaluation Report Evaluation of the Community-based Care Transitions Program (
Impact of Hospital Discharge Planning on Meeting Patient Needs after Returning Home (
Hospital Readmission Among Older Adults Who Return Home With Unmet Need for ADL Disability (

The information contained in this article is for informational purposes only and is not intended to constitute medical, legal, or financial advice or to create a professional relationship between AgingCare and the reader. Always seek the advice of your health care provider, attorney or financial advisor with respect to any particular matter, and do not act or refrain from acting on the basis of anything you have read on this site. Links to third-party websites are only for the convenience of the reader; AgingCare does not endorse the contents of the third-party sites.

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