My Mom Is Coming Home From the Hospital. What Should I Expect?

Mom Is Coming Home—but She Isn’t Back to Normal

Your mother is medically ready to leave the hospital.

That is good news. But she may not be functioning the way she did before she became ill.

Maybe she walked independently before hospitalization but now needs a walker. Maybe she needs help getting out of bed or getting to the bathroom. She may be weaker, tire more easily, or need help with medications, meals, bathing, or dressing.

Families sometimes hear “ready for discharge” and assume that means the patient has returned to their previous level of independence.

It does not.

A patient can be medically ready to leave the hospital while still needing considerably more help than before hospitalization.

If your loved one is coming home with new limitations, the most important question is not simply:

“Is she ready to leave the hospital?”

It is also:

“What will she need at home, and who will provide it?”

Start With What Has Changed

Before making plans for home, compare what your loved one could do before hospitalization with what they can do now.

Consider basic daily activities:

• Can she get in and out of bed?
• Can she stand up from a chair?
• Can she walk safely?
• Can she get to and use the bathroom?
• Can she bathe and dress herself?
• Can she prepare something to eat?
• Can she manage her medications?
• Can she safely be left alone?
• Is she thinking clearly enough to recognize problems and ask for help?

Do not assume these needs will disappear simply because the patient is going home.

Some limitations may improve quickly. Others may take weeks or longer.

The discharge plan should address what the patient can safely do now, not what everyone hopes the patient will be able to do next week.

What Can Home Health Provide?

Many patients who return home after hospitalization receive home health care.

Home health can bring skilled healthcare professionals into the home while the patient recovers.

Depending on the patient’s needs, services may include:

• Skilled nursing.
• Physical therapy.
• Occupational therapy.
• Speech therapy.
• Medical social services.

Physical therapy may work on strength, balance, walking, transfers, and the safe use of a walker or other equipment.

Occupational therapy may help the patient regain the ability to perform everyday activities such as dressing, bathing, toileting, and preparing simple meals.

A nurse may monitor a medical condition, assess wounds, provide education, review medications, or perform other skilled nursing services.

The overall goal is to help the patient recover and become as independent as possible.

Home Health Does Not Mean Someone Will Be There All Day

This is one of the most important things for families to understand.

Home health usually consists of scheduled visits.

A nurse or therapist comes to the home, provides the needed service, and then leaves.

Patients often receive two or three home health visits per week, although the frequency varies according to the patient’s needs and insurance coverage. Individual visits may last roughly 45 minutes to an hour.

That leaves many hours during the week when no home health professional is present.

A patient may therefore qualify for home health and still need considerable assistance from family members or other caregivers.

Before discharge, make sure everyone understands that distinction.

The Custodial-Care Gap

A patient may need help at home that is important but is not the primary purpose of home health.

Help with everyday activities such as bathing, dressing, toileting, meals, mobility, and supervision is often called custodial care or non-medical care.

Consider a patient who can walk only short distances with a walker and needs someone nearby when getting up.

Physical therapy may help that patient become stronger and safer over time.

But the physical therapist will not be there every time the patient needs to get up to use the bathroom.

That gap between intermittent professional care and day-to-day assistance is something families need to plan for.

For some patients, the gap is small.

For others, it may be the biggest challenge involved in returning home.

What Can the Family Realistically Provide?

Families naturally want to help.

But willingness to help and the ability to provide the care someone needs are not always the same thing.

Be realistic about:

• Who is actually available.
• Work and school schedules.
• Whether someone can stay overnight.
• Whether family members can physically help with transfers or mobility.
• How far away family members live.
• How long the increased level of assistance might be needed.
• Whether the patient can safely be alone for portions of the day.

Avoid building a discharge plan around help that probably will not be available.

It is better to identify a caregiving gap before leaving the hospital than to discover it after the patient is already home.

Tell the hospital case manager honestly what the family can and cannot provide.

What If the Family Cannot Provide All the Help Needed?

There may be several ways to supplement the help family members can provide.

Private agencies provide non-medical caregivers who can assist with personal care, meals, mobility, supervision, and other everyday needs.

These services are usually paid for out of pocket, which may make extensive private caregiving unrealistic for some families.

Medicaid programs in some states may pay for certain personal-care and home- and community-based services for people who meet eligibility requirements.

Family members, friends, neighbors, and other supports may also be able to divide specific responsibilities rather than expecting one person to provide all of the care.

Home health visits can sometimes be scheduled strategically. For example, a therapy visit during the middle of the day may be particularly useful when family members are working or at school.

There is rarely one perfect solution.

The goal is to build a realistic combination of services and support that addresses the patient’s actual needs.

Know What Is Arranged Before Leaving the Hospital

If home health is part of the discharge plan, ask the hospital case manager for the name and phone number of the agency that has accepted the referral.

Call the home health agency.

Confirm:

• That the agency has accepted the patient.
• What services are expected to be provided.
• When the first home visit is expected.

Also make sure you understand any equipment that is being arranged, such as a walker, wheelchair, bedside commode, oxygen, or other medical equipment.

Know which prescriptions need to be picked up and when follow-up appointments are scheduled.

Most importantly, know who will be helping the patient during the hours when home health staff are not there.

What If Insurance Limits Home Health Visits?

Patients with Medicare Advantage or commercial insurance may need ongoing insurance authorization for home health services.

An insurance company may initially approve home health and later limit the number of additional visits it will cover.

Sometimes the home health agency believes continued services are needed, but the insurance company will not authorize them.

If that happens, ask the home health agency:

• What services are being reduced or stopped?
• Why does the agency believe continued care is needed?
• Has additional authorization been requested?
• Has the insurance company denied the request?
• Is there an appeal or reconsideration process?
• What alternatives are available?

Also call your insurance company directly. Ask why additional services were not authorized and what you can do if you disagree with the decision.

Do not assume that the home health agency and insurance company are making the same recommendation.

Questions to Ask Before Going Home

Before leaving the hospital, consider asking:

• What can the patient do independently right now?
• What activities will require help?
• Can the patient safely be left alone?
• What home health services are being arranged?
• Which home health agency has accepted the patient?
• When is the first visit expected?
• What medical equipment will be needed?
• Who will help with bathing, dressing, toileting, meals, and mobility?
• What will happen during the hours when family members are at work or school?
• What should we do if the patient needs more help than we expected?

Write down the answers.

You do not need to anticipate every possible problem.

But you should understand the patient’s current needs and have a realistic plan for meeting them.

The Bottom Line

Coming home from the hospital does not mean that recovery is finished.

For many patients, it is the beginning of the next stage of recovery.

Home health can provide important nursing and rehabilitation services, but it does not provide continuous caregiving.

The key is to understand the patient’s new limitations, know what professional services will be available, and identify who will provide the additional help the patient needs between visits.

A realistic plan does not require everything to be perfect.

It requires everyone to understand what the patient needs and who is actually available to help.

How HNav Can Help

Bringing someone home after hospitalization can feel overwhelming, particularly when their abilities and care needs have changed.

HNav helps patients and families understand what the discharge plan actually provides, identify potential gaps, and ask practical questions before leaving the hospital.

Our goal is to help you understand what will be needed at home so you and your family can make informed decisions about the next stage of care.