A Hospital-to-Home Checklist Can Help Avoid Trouble

Patients are typically eager to return home after a stay in the hospital, but common mistakes often lead to unnecessary re-admissions. The good news is, a hospital-to-home checklist is a simple and effective tool for reducing that risk.

Home To Hospital

Somerville-Cambridge Elder Services (SCES) offers several programs that can enhance health, well-being and independence for patients returning home from the hospital. We recommend the following steps for success:

  • Make sure to get a copy of the discharge plan that outlines any new care needed at home or new prescriptions.
  • If the return home includes a stay at a rehab facility, be clear on the costs and services provided.
  • Understand the costs of the hospital stay. Contact the hospital’s financial office or the SHINE program at SCES for more information.
  • Determine if home modifications are needed.
  • Make an appointment with your primary care doctor, preferably within a week of discharge.
  • Arrange for home delivery of medications, if needed.
  • Request home care services through a local Aging Services Access Point (ASAP), for assistance with personal care, homemaking and other needs.
  • Consider if care management is needed. A Private Care Manager (PCM) can coordinate details of the transition to home.

SCES also provides several community resources that can assist with hospital-to-home transitions:

  • The SCES Hospital-to-Home program coordinates with primary care providers and the visiting nurse association to provide community resources and make referrals. Offered through a partnership with Cambridge Health Alliance, this program is free for patients with Medicare A&B.
  • As an ASAP, SCES provides home care services for Cambridge and Somerville residents, many of which are free for eligible households.
  • SCES offers PCM services through Community Living Options (CLO), and the program can manage all aspects of hospital-to-home transitions, along with meeting ongoing care needs.

SCES launched the CLO program earlier this year to address the unmet need for comprehensive and ongoing service for those who don’t meet government eligibility restrictions. The care managers at CLO are nurses and social workers, who specialize in assisting clients and families with challenges of aging and disability throughout the life continuum, said SCES Director of Program Development Tiffany Bruschi-Barber.

“Creating a smooth hospital-to-home transition can be a real challenge,” said Bruschi-Barber. “The value of an expert PCM is the time, money and energy they can save patients and their families.”

By: Colleen Morrissey, an SCES Resource Specialist. SCES programs can be accessed by calling the Aging Information Center at 617-628-2601. CLO can be reached by calling 617-756-1026.