8 Steps to Ensuring a Smooth Transition Home From the Hospital
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8 Simple Steps to Ensuring a Smooth Transition Home From the Hospital and Reducing the Chances of Readmission

Readmission to the hospital is a growing problem for America’s healthcare system. Data analyzed by Medicare says about 20 percent of the 35 million patients discharged from the U.S. health system return to the hospital within the 30 days.

Not having a strong and well-understood hospital to home care plan is one of the leading reasons patients find themselves returning to the hospital within days or weeks of discharge. Luckily, there are many easy-to-implement steps that can help prevent readmission.

Here are eight simple steps to preventing readmission for you or a loved one:

Geek out with technology

Technology isn’t just for posting photos of your grandkids or watching a favorite show. Technology can be used for everything from in-home sensors, smart phone apps, remote monitoring, to assisting and promoting patient care and engagement. A recent Mayo Clinic study says mobile and in-home devices have led to a 40 percent decrease in hospital readmission for cardiac rehabilitation patients (who are among the largest group readmitted).

Before leaving the hospital, ask if utilizing technology to record, monitor, and report daily healthcare data and activities should be part of your hospital to home care plan.


Miscommunication is responsible for about one-quarter of all readmissions, says a 2016 study published in JAMA Internal Medicine. “Asking questions is the easiest way to foster clear and concise communication,” says Katie Goodman, MSSA, LSW, a social worker at Marcus Pavilion /Menorah Park, a skilled nursing facility in Beachwood, Ohio.

“There are no ‘silly’ questions and neither patients, nor their family members, should ever hesitate posing any question to the physician, treatment coordinator, discharge nurse, etc.”

Goodman suggests asking questions about recommendations for home care needs, the need for skilled nursing or skilled therapy, the degree of help recommended for activities of daily living, and where you can hire help. “You can also ask about any specialized equipment needed, about home exercise therapy programs, and so on.”

Not sure who to ask? Goodman says “one good resource is the social worker or case manager in the facility or hospital, who answer questions constantly throughout the day.”

Think beyond medical care

Too often patients and their loved ones attempt to shoulder the responsibility of transitioning home from the hospital on their own. However, building a connected care circle to rely on helps provide ongoing education, support and care oversight that increases patient outcomes and helps to prevent hospital readmission.

Before leaving the hospital, inquire about community support like Meal on Wheels programs or visiting clergy, as well as health services like physical therapy and/or follow-up visits to a physician or specialist. Goodman says utilizing such services can enhance a patient’s overall health and well-being, to lessen the chance of hospital readmission.

Manage medication

An analysis by the American Geriatrics Society says educating patients and their families prior to discharge cuts the chance of readmission by 25 percent. This includes brushing up on dosing and timing of all medications—including any newly added to a treatment plan during the trip to the hospital.

Amelia Roberts, BSN, RN, a registered nurse care coordinator in Washington D.C., says at-home medication errors is a huge problem. “Medication errors at home can send people back to the hospital. Sometimes people get home with new medications and are unsure what to do with the old medications they still have at home. They may still take the old medicine which can have an adverse reaction or not taking the new or correct medication properly.”

Roberts suggests asking for a detailed and written medication plan patients and their family or advocate can refer to in the event at-home questions arise. “Make sure it indicates what—if anything—to do with other medicines the person was taking to avoid any confusion.”

Follow up

Before leaving the hospital, schedule and follow-up with appointments with a primary physician or required specialists within 10 days of discharge.

This step can slip through the cracks once a person is home and settling in. But it’s an important part of the hospital to home care plan that can help prevent readmission. The follow-up visit is a time to review medication adherence, side effects, etc., as well as physical therapy progress or wound/incision healing. It’s also a chance to ask questions that may help prevent confusion or complications that lead to readmission.

Fill the fridge

Having access to fresh food that complies with a person’s discharge plan is essential. Proper nutrition and foods that speed up recovery after surgery can aid the healing process post-surgery, help boost or sustain energy to successfully participate in physical therapy, and even help adherence to medication that need to be taken with food to prevent nausea or maximize absorption.

Keep an eye on exercise

Goodman says another leading cause of returning to the hospital or skilled nursing facility is patients not maintaining the recommended exercise programs assigned by their physical therapist.

“The best we can do is ensure patients and their caregivers are educated on the importance of keeping up with exercise,” she explains. That includes having a written home exercise program with pictures on how to do the exercise.

“Patients should be set up with home care which includes a nurse and therapist visiting in their home setting and checking up regularly to insure exercising is occurring as prescribed.”

Speak up

Goodman stresses that no matter the circumstance, question or issue, the easiest way to ensure a smooth hospital to home transition is using your voice. “Never hesitate asking a question, explaining a concern or bringing up a change in your symptoms, care needs or ability to comply with recommended treatments. In many instances, that can be how to prevent hospital readmission.”


  1. https://www.ncbi.nlm.nih.gov/books/NBK91986/
  2. Mobihealthnews.com
  3. MDEdge.com
  4. HCPro.com

About the Author(s)

For over two decades, Gina Roberts-Grey has pored over studies and interviewed leading health experts on topics ranging from healthy aging, caregiving and longevity. Having been an active caregiver to her grandparents who lived into their 90’s, Gina is passionate about supporting caregivers through their journeys. Her work has been featured in publications like Woman’s Day, AARP, Oprah, Neurology Now and many more.

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