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Managing the Transition from Hospital to Home or Rehab to home

Transitioning from hospital to home or Rehab to home can be challenging at times.
Nurse showing a caregiver pushing an elderly woman in a wheelchair documents on a clipboard in a hallway
Home Care in Swampscott MA

Transitioning from hospital to home or Rehab to home can be challenging at times. It comes with excitement and stress for patients and their caregivers. There are issues and some few questions family members or caregiver need to tackle before making this transition. The key to making transition is planning.

We have outlined some few tips below to make the transition smooth and safe for you and your loved ones:

  • Plan ahead of time: Planning ahead of time help decrease anxiety and stress that comes with care transitions. Start talking to your loved ones about their needs, wishes, preferences, and desires.
  • Do your research ahead of time: Do not wait till the last minute to start looking for who will care for your loved. Understand different programs and insurance coverage that can pay for your loved ones to continue living at home after hospitalization or rehabilitation. Arrange for medical equipment, meals, prescription pick up, personal care or home modification.
  • Get Help: If you are overwhelmed or unable make the transition smooth and safe due to distance, you can seek help form case managers and geriatric case managers.
  • Look for local and community resources: Many communities have available resources that can help you and your family member. Such as: respite care (time away from caregiving) for family caregivers, counseling, support groups family caregivers, help with transportation or financial assistance, and friendly volunteer visits for your family member.
  • Be realistic and have a realistic expectation: Staying real to current situation is very important when it comes to transitions. Will your loved one needs to be safe at home. What happen that make him or her to go hospital or rehab. Will your loved one be able to take his or her medication while at home. Is home setting the right place for your loved one or family member.
  • Ask questions: Asking question is very important, it helps clarifies doubts. Also make a list of question to ask before the discharge from the skilled nursing facility or hospital.

Plan for Routine Care Responsibility: Another concern is who will be responsible for providing activities of daily living (ADLs). Some common care responsibilities you may be performing when your family member return home include:

  1. Personal Care: Eating, bathing, toileting, repositioning if the patient is unable to move.
  2. Household Care: Cooking, Cleaning, Laundry, grocery shopping
  3. Emotional care: This includes socialization, companionship and engaging in an activity.
  4. Health care: physicians’ appointments, medication management, wound treatment and, medical equipment.

For routine care, things might become difficult if your family member is unable to perform ADL, unable to move or confuse due to illness or have restrictions after surgery. The family have the option to provide routine care by themselves or hire a caregiver from home care agency or hire their own personal caregiver, consider the pros and cons of each option.

To hire a home care agency, you should contact your local elder services, look online for local home care agencies. Friends and family recommendation can also be a great help when finding home care agency to care for your loved one.

Home Care Agency Pros and Cons


  • Background checks has been performed on each caregiver
  • Professional liability insurance and worker’s compensation
  • Home care agencies offer backup caregivers when the primary caregiver cannot work
  • Training and benefits are offered to staffs
  • Professional supervision of caregivers and performance evaluation are performed.


  • More expensive
  • May have staff turnover

Private Hire


  • Less expensive
  • More flexibility in tasks
  • Difficult to find alternate help if your private aide is sick or unable to work.


  • You are responsible for carrying all insurances, including liability insurance.
  • You are required to comply with IRS Publication 926 – classification of household employees
  • You must withhold taxes and remit them to the IRS at pre-determined intervals.
  • You are responsible for employee payroll, tax deduction, and withholding social security, Medicare, and unemployment taxes as required by law.
  • Liable for job-related accidents in your home.

By Ogechukwu (Oge) Anuta RN BSN
Nurta Home Healthcare
To learn more about your care option contact us at (781)-300-7495

Ogechukwu Anuta

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