As a concerned spouse, family member, or friend, transitioning an older adult from hospital to home can be challenging. In addition to creating a safe and comfortable home environment, other steps must be taken to ensure they receive the care they deserve. If not, your loved one could find themselves at higher risk of being readmitted to the hospital. Using these transitional care guidelines as a reference could be a real game-changer when your loved one’s recovery weighs in the balance.

Transitional Care Tips for Seniors

Be sure to include these steps in your transitional care action plan:

Be supportive

Adjustments that accompany a recovery can be notably difficult for stubborn seniors. As a caregiver, go in with an open mind, be willing to communicate and listen patiently, and remain as empathetic as possible. Although your loved one might be angry, frustrated, depressed, or anxious, don’t allow those negative emotions to keep you from giving them the love, attention, and support they need.

Use a team approach

Although the period after a hospital stay can feel like a whirlwind, allow plenty of time to consult with your senior’s doctors, surgeons, and other healthcare specialists. Numerous tasks will need to be managed, like housekeeping, meals, rehab appointments, medication reminders, etc. Develop a schedule based on those needs, and don’t be afraid to involve other trusted family members and friends in the process.

Modify the home environment

After a hospital stay, your loved one may have difficulty getting around, or they could be experiencing pain, medication side effects, or noticeable changes to their hearing or eyesight. At that point, falling becomes a real possibility. Create a safer home environment by moving furniture out of walking paths, adding more lighting, and installing grab bars in the bathroom.

Prioritize caregiving tasks

For at least the first few weeks, you may be asked to help coordinate numerous tasks such as home health visits, doctor’s appointments, therapy sessions, and medication refills. Based on your loved one’s ability to perform activities of daily living (ADLs), you might need to assist them with bathing, housekeeping, meals, and more. Rather than get overwhelmed, prioritize daily or weekly tasks based on their level of importance.

Ask for help

Being a primary caregiver can be a physically, emotionally, and mentally exhausting job. Avoid caregiver burnout by bringing on an extra pair of hands from sources like:

How Home Instead of Southwest Florida Can Help

As a licensed senior home care provider in Southwest Florida since 2002, Home Instead has helped more than 1025 families seamlessly transition aging loved ones from hospital to home. With an average client tenure of 57 months, we use the latest operations software to track how many falls our clients have, along with hospitalizations, hospital readmissions, and other metrics.

Falls, hospitalizations, and readmissions are difficult challenges as we are not solely responsible for those metrics. That said, we are proud of the fact that client who falls with a Home Instead caregiver present are very rare, with an incidence rate of 0.28%.

Additionally, only 5% of the client population under our care has had to be hospitalized during the last four years. In our line of work, readmission reduction is the name of the game in post-acute care. Because we struggle with not always being in complete control of the situation, non-compliance issues often drive these numbers. For example, a client may not follow the prescribed plan of care, leading to a medical crisis, hospital visit, and potentially readmission.

A Recent Client Case Study

As a recent example, a client came to us after falling and breaking her same hip a second time – an unfortunate situation documented as readmission. Our experienced caregivers were with her for four months as she recovered, during which time she had no falls and quickly regained her mobility and strength.

After an incident-free recovery, she and her family decided to terminate care with us because the client was feeling confident in her ability to live independently without help. Two weeks after they terminated care, she fell and re-broke the same hip for the third time – which our documentation shows as a fall and hospital readmission. Luckily, the client was eventually well enough to be discharged back home and placed once again under our care.

Why Place Your Trust in Our Post-Acute Care Services?

Even with non-compliance issues and other factors outside our control, the hospital readmission rates for Home Instead clients are extremely low, with an average 90-day readmission rate of only 3.25% over the last four years. To learn more now about our transitional care services for seniors in Naples, Fort Myers, and Charlotte County, FL, please visit us at