How to Transition to In-Home Care After a Hospital Stay

Coming home from the hospital is a milestone—but it also marks the start of a critical recovery phase. Properly transitioning to in-home care ensures your loved one receives continuous support, reduces the risk of complications or readmission, and promotes a smoother, more comfortable healing process. Here’s a step-by-step guide to a seamless handoff from hospital to home-based care.

1. Start Discharge Planning Early

Engage the Care Team

• Ask Questions Before You Leave: Clarify wound-care protocols, weight-bearing restrictions, medication schedules, and follow-up appointments.

• Request Documentation: Ensure you receive a complete discharge summary, including lab results, imaging reports, and physician orders.

Coordinate With Your In-Home Care Agency

• Notify Maxona Care in Advance: We can begin creating a preliminary care plan based on your expected needs, so a caregiver is ready when you arrive.

• Share Medical Records: Fax or upload discharge paperwork and medication lists to your Care Coordinator for review.

2. Prepare Your Home Environment

Clear Pathways & Eliminate Hazards

• Remove loose rugs, cords, and clutter from hallways and common areas.

• Install nightlights in bedrooms, bathrooms, and corridors to prevent trips during late-night awakenings.

Set Up a Recovery Zone

• Comfortable Rest Area: Choose a main-floor room close to a bathroom. Stock it with pillows, blankets, water, and a phone within reach.

• Essential Supplies: Have dressings, gloves, hand sanitizer, and cleaning wipes accessible for wound-care needs.

Install Safety Features

• Grab bars near the toilet and in the shower.

• Non-slip mats in the bathroom and next to the bed.

• A sturdy, easy-use walker or cane, if prescribed.

3. Define the Scope of In-Home Services

Activities of Daily Living (ADLs)

• Personal Care: Bathing, dressing, toileting, and grooming assistance.

• Mobility Support: Safe transfers, walking supervision, and proper use of assistive devices.

Instrumental Activities (IADLs)

• Medication Management: Reminders, pill organizer setup, and monitoring side effects.

• Meal Preparation & Nutrition: Cooking physician-recommended meals, hydration checks, and grocery runs.

• Light Housekeeping: Laundry, dishes, vacuuming, and bed-making to maintain a sanitary environment.

Medical & Clinical Tasks

• Wound-care changes under nurse supervision.

• Vital signs monitoring (blood pressure, pulse, temperature).

• Coordination with physical or occupational therapists for prescribed exercises.

4. Selecting & Onboarding Your Caregiver

Interview & Matching

• Cultural Fit & Personality: Meet prospective caregivers in person to gauge rapport and communication style.

• Skill Verification: Confirm licensure, training in post-surgical and wound-care protocols, and CPR/first-aid certification.

Trial Visits

• Schedule an initial “meet-and-greet” before the hospital discharge to introduce your loved one and review the care plan.

• Use this opportunity to walk the caregiver through daily routines, emergency contacts, and any special instructions.

5. Establish Clear Communication Channels

Daily Visit Summaries

• Caregivers from Maxona Care leave concise notes on tasks completed, any changes in condition, and upcoming appointment reminders.

Family & Care Coordinator Check-Ins

• Schedule brief phone or video updates each evening to share observations and adjust care as needed.

• Use a secure online portal or simple group text to keep all family members informed in real time.

6. Monitor Progress & Adjust Accordingly

Track Key Metrics

• Wound Healing: Note changes in redness, drainage, or pain levels.

• Mobility Gains: Record distance walked, endurance, and any episodes of dizziness.

• Medication Adherence: Ensure doses are taken on time and note any side effects.

Regular Care Plan Reviews

• Your Care Coordinator meets (virtually or in person) weekly during the first month to revise the care schedule, add new services, or reduce hours as your loved one regains strength.

7. Plan for Emergencies & Next Steps

Emergency Protocols

• Post clear instructions for calling 911, contacting family members, and reaching Maxona Care’s 24/7 support line.

• Keep all caregivers and family members aware of the nearest urgent-care or hospital facility.

Long-Term Goals

• As recovery milestones are met, discuss transitioning from high-intensity care to fewer daily visits or respite care, ensuring sustainable support.

A Confident, Safe Return Home
A well-executed transition to in-home care prevents gaps in service, promotes faster healing, and gives families the peace of mind they need. With Maxona Care’s rapid-start onboarding, personalized care plans, and continuous support, you’ll have a trusted partner at every stage of recovery.

Ready to get started? Contact Maxona Care at (470) 756-1751 or visit www.maxonacare.com to schedule your free post-discharge assessment and ensure a smooth, safe return home for your loved one.