Hospital stays end with the discharge, correct? Not always. 

The reality: Poorly understood care instructions and/or inadequate care are the prime causes for readmissions to hospitals. Following the detailed care guidelines outlined by the hospital staff is critical to achieving a full recovery.

When an elderly person has experienced an illness or undergone surgery, are they going to recall the details of their discharge? Their thinking is likely clouded by anesthesia, pain medication and sheer exhaustion. 

Are they equipped to make critical decisions about their transition of care? Most likely not.

We’ve all heard “it takes a village.” This is particularly true for elders experiencing a health crisis. It is my belief that no matter the age, hospital stays require an advocate: someone of sound mind, someone who can ask questions and take written notes, a competent spouse, caring family members or even hired professionals to serve as our sounding boards and advocates.


The discharge process

First of all, the discharge process is not the 15 minutes prior to heading out the hospital door. Over the course of a day or two, discharge planners initiate conversations that assist with transitioning from hospital care to our next stage of care. It’s important that family members or an advocate be part of these discussions. The planner suggests care options and lays out guidelines.

An elder could choose to return to his or her family home. Or circumstances may dictate moving temporarily to assisted living or transitional care. If needed, nursing homes provide acute care.

After a three-day hospital stay, Medicare will pay (for a limited time) the cost of an elder’s recovery care and housing at assisted-care or nursing facilities. The discharge planner provides a list but will not recommend a specific facility because that would be a conflict of interest. Choices are limited to what is covered by the elder’s insurance.

At discharge, medications are supplied with instructions on how to administer them. Wound-care directives are given orally and sometimes in writing. Restrictions on movement and activity are discussed.

The mode of transportation is determined; choices range from the family car (with a driver), to a cabulance (which transports persons in wheelchairs) or an ambulance. Phone numbers are furnished so that appointments can be set up for nurse visitations and physical therapy sessions at home. 

Ranging from in-home to institutional, the needed level of care determines the most suitable option. The correct level of care is critical for recovery.


Making decisions

The bottom line: The patient or the patient’s representative self-directs the transition of care.

Most often, the sentimental choice is to go directly home, but the level of care required for the safety of the individual may be inadequate. 

Here are some questions to ask yourself: Who will be “on-call” to provide the assistance for getting in and out of bed, for going to the bathroom, wound care, medications, bathing and dressing and meal preparation?

During the first days of recovery, 24-7 care may be required. Will the spouse and/or family members have the strength, time and skills to provide care? If not, are they willing to hire skilled help to assist?

If you’ve never experienced it, an elder’s transition from hospital to recovery care can be intimidating, even overwhelming.

To ease the process, I suggest that you and your elder meet with the elder’s primary-care doctor and surgeon prior to a hospital stay. You’ll gain an understanding of what to expect. Agreements can be made about the amount of support the family provides. 

By visiting care facilities prior to the hospital stay and by talking to caregiver professionals, both elder and family will understand which options offer the best opportunities for transitioning back to good health. 

Upon leaving the hospital, the goal is full recovery and a quick return to the home environment the elder treasures. By understanding and actively participating in the discharge process, you will be laying the foundation.

MARLA BECK is the founder and president of Andelcare Inc., which provides in-home eldercare. Submit questions by calling (206) 838-1844 or via e-mail to