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The Transition to Home Care

By planning in advance, nurses can keep patients healthy and out of the hospital

This offering expires in 2 years: June 23, 2010

The goal of this continuing education offering is to provide nurses with current information on transitioning patients to home care. After reading this article, you will be able to:

1. Describe how home health planning begins with admission to healthcare services.

2. List nine key patient assessments to determine whether home discharge is safe.

3. Explain the four pillars of discharge planning established by the Care Transitions Program.

4. Identify six key elements of information that should be provided to health professionals in the next phase of care.

You can earn 1.5 contact hours of continuing education credit in three ways: 1) For im-mediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).


When a patient is discharged to home care, facilitating a secure transition and safe and appropriate care is a multistep process that focuses on assessment, planning and communicaton. Patients discharged to their homes are at high risk for landing in unsafe situations because they don't have the continuous professional supervision that's commonly available in acute care hospitals, rehabilitation and skilled nursing facilities. Patients with multiple medical problems and patients who are elderly are at particular risk.1Think about your nursing practice. Do you spend at least as much time on a patient discharge as you do on an initial admission assessment? If not, your patients could be at risk for mishaps related to discharge misunderstandings. Remember, your discharge is essentially an admission to the next healthcare setting, particularly if you are sending someone home without in-home professional care.1The conditions listed below are associated with the need for post-hospital care in skilled nursing facilities or by skilled home care professionals, and at a higher potential for transition complications.2The percentage represents hospital discharges for Medicare beneficiaries (as available).3

  • Cardiac dysrhythmias (particularly atrial fibrillation with anticoagulation)

  • COPD (4 percent)

  • CHF (6.3 percent)

  • Coronary artery disease (9.7 percent)

  • Diabetes

  • Hip fracture (3 percent)

  • Medical and surgical back conditions

  • Peripheral vascular disease

  • Stroke (4.1 percent)

Planning Starts at Admission

Whenever you admit a patient to the emergency department, hospital or other facility, ask if the patient has a relationship with a home health agency or a preference for one on discharge. While home care agencies encourage patients to call the agency before heading out so the agency's nurse or therapist can help facilitate the care transition, patients and their families often make their own decisions, and the primary home care nurse may not know about a patient's visit or hospitalization. Patients may forget to tell nurses at ambulatory surgery centers they have a home care nurse.

If the patient is under an agency's care, the home care nurse can save you time and reduce the risk for errors by providing a current list of medications, active diagnoses, pertinent history, baseline assessments and a snapshot of the patient's recent condition at home. This type of nurse-to-nurse report can make medication reconciliation from home to facility much safer than relying on either a patient who is acutely ill or injured or an upset caregiver's memory.

Moreover, the home care nurse can provide insight into the patient's home situation and whether the physical layout and the arrangement with caregivers is a safe one that can be flexible with changes in the patient's condition. A situation that is reasonable when the person is fully ambulatory may be unsafe if the patient is weakened by an acute infection, such as a urinary tract infection or community-acquired pneumonia, or if the patient sustains an injury. If a patient is already receiving care from an agency, resuming services on discharge is far easier than an initial eligibility determination.

Regardless of your practice setting, be aware of the home care agencies in your area and programs available to help at-risk people in the community reduce rehospitalizations or long-term institutional placement. In your practice setting, a discharge planner or social worker may contact the agency on the patients' behalf, but if you're aware of the options on discharge, you can be proactive and start the process early on.

For example, in Connecticut the regional Agencies on Aging provide funding for care for seniors who are dually eligible for both Medicare and Medicaid (see It is much less expensive to provide daily home health aides for assistance with personal hygiene and a few hours of homemaker services to make a meal and provide companionship for frail elders who might otherwise end up in an institutional setting because they are unable to manage safely alone all day, every day, in their own homes.

Medicaid & Medicare

Medicaid programs are run at the state level, as states are required to administer Medicaid funds. Sometimes, this funding is referred to as "money follows the person" after the initial Congressional proposal first introduced in 2003. The goal of this funding is to allow the patient and family to make choices about where care is provided, rather than being forced into institutional care as the only option covered by the benefit. Your local home health agencies will be able to provide you with this information and help coordinate with discharge planning nurses or social workers to optimize resources available in the commuity for a variety of patient circumstances.

Medicare pays for home health services when the beneficiary is homebound and unable to easily travel around the community for care. Homebound individuals are not necessarily bedridden, and may go to a physician's office for occasional visits or attend religious services from time to time, but leaving home must require a "considerable and taxing effort," and typically involves the use of assistive devices, help with transportation and a companion.4If patients can go shopping regularly or are going to work, they will not be considered homebound and Medicare will not pay. Homebound status is continually reassessed by the home health provider.

For example, my agency cares for many patients who are homebound following major orthopedic surgery, such as joint replacements. We provide home physical therapy, nursing care and home health aides until patients regain their strength and balance and can leave their homes safely and transition to outpatient therapy services in the community. An elderly woman who fractures her ankle may not need to be hospitalized, but will very likely be homebound and eligible for home physical therapy if she is not permitted to bear weight on the injured leg and needs to learn to use a walker or other adaptive devices to move around safely within her home. She would be unable to, for example, drive to and walk around the grocery store.

Private insurance plans present as many rules as there are policies. However, if a case can be made that home care services can prevent or shorten a period of institutional care, case managers will sometimes authorize services because home care is much less costly than any institutional care (as long as it is safe).

Assessing for Safe Home Care

The first element of a home health plan of care is ensuring the patient is safe. Agencies may turn down a referral if the agency believes the proposed situation for care at home is unsafe or if the agency doesn't have the resources to ensure home safety (such as an agency that doesn't provide 24-hour caregivers).

Sometimes, we can't fully assess a situation until a few days have passed and nurses and aides are in the home evaluating the patient and caregivers. This assessment for safe discharge has become more of a challenge for acute care professionals today because community-based physicians who have long relationships with patients and their families are not managing their inpatient care now that hospitalists are available.

A devoted wife may earnestly tell the hospitalist and hospital-based nurses she will care for her husband when he is discharged, but her limitations may not be evident to acute caregivers who are unfamiliar with her and the home situation. Or, family members who initially agree to stop by the home every morning may not show up after the second or third day. Or, meals may not be delivered or heated up for a patient who cannot prepare food himself. Don't hesitate to check with community care providers who know the patient and family well to help determine the suitability of a discharge to home before all the discharge paperwork is done. Again, this is the type of information that should be received and followed up on at admission.

On admission to home care, Medicare requires we assess the patient's ability to accomplish very specific activities of daily living. Before sending patients home, ask them to describe in detail how they will accomplish certain tasks, such as going to the bathroom or using a commode (and emptying it), transferring in and out of bed or a chair, walking or using assistive devices to get around the home, preparing meals and eating (particularly if a special diet is prescribed), and managing personal hygiene and dressing.

If a patient is "trapped" in bed or a chair because she cannot transfer and a caregiver can't lift, that's simply unsafe. Remember, a patient may be hampered because he cannot get an assistive device delivered to the home that would otherwise allow him to be mobile, so be sure to check how a patient will get assistive equipment and devices, such as walkers, raised toilet seats and grab bars, or services such as Meals on Wheels.

Knowledge-Based Elements

It's also critical to assess the patient's cognitive abilities and determine if any deficits will affect safety. The Society of Hospital Medicine (SHM) published a discharge checklist for hospitalists after research showed one in five elderly patients experiences an injury resulting from medical management or misunderstanding - rather than from the underlying disease - in the transition from hospital to home. More than half of these injuries can be prevented with proper assessment, planning and communication during the discharge phase of care.1Key knowledge-based elements include:

  • name of each medication, schedule for taking, and reason for medication;

  • comparison with preadmission medications, indicating which are new and which should no longer be taken;

  • date, time and place of follow-up appointment(s) with community-based care provider(s); and

  • anticipated problems or potential deterioration of condition and action(s) to take, along with expected changes such as postoperative pain and its proper management.

At baseline, many patients will not be able to articulate each of these elements. However, a responsible adult must be available who can and is willing to take responsibility for the patient's care at home.

Planning a Successful Discharge

As a former ED nurse, a wise mentor taught me that, rather than providing a list of discharge instructions, a much more effective approach was to ask the person or caregiver what she would do in certain circumstances.

Once, we were ready to send a mother home with a child who had what seemed to be a viral syndrome with a fever. The physician wrote instructions to take the child's temperature every 4 hours. I asked the mother what she would do if the temperature was 103¡ F. She explained she would bundle the child up and walk a half mile up the road to the neighbor, who had a telephone, since hers had been disconnected.

That child was admitted to the hospital. I believe if I said, "Take her temperature every 4 hours, OK?" the mother probably would have nodded in agreement, and I would have thought we had a safe discharge plan.

Four Pillars

Researchers from the Care Transitions Program have established four pillars necessary to build successful transitions from hospitals and skilled nursing facilities to home: medication self-management, a patient-centered personal health record, follow-up instructions and red flags the patient needs to be aware of.2

Implementing these elements in a coordinated plan for 375 seniors saved more than $295,000 in reuced rehospitalizations and ED visits.51. Medication Self-Management: The goal of this discharge element is for the patient to be knowledgeable about medication and to have a system in place so he takes the right medicine in the right dose at the right time. This teaching needs to take place prior to discharge and can be followed up with home visits by the agency and telephone calls for clarification.

2. Personal Health Record: This pillar's goal is to establish an accurate, personal record for each patient that can be shared with healthcare providers across the continuum of care and in a variety of settings. A sample of this tool is available at the Care Transitions Web site ( Clinicians may use these tools without copyright restrictions. The nurse can start the process while preparing for discharge, then the patient, his family and his healthcare providers can help fill in the rest of the information on the record.

3. Follow-Up Instructions: This element is simple. The patient needs to schedule visits with community-based providers and take the responsibility for keeping the appointments, asking questions and clarifying the ongoing plan of care.

4. Red Flags: Patients and their caregivers need to know the red flags that indicate their condition is worsening, what to do and when to seek assistance. From a home care perspective, it's also important for patients to know what to expect, such as not being totally pain-free after surgery, expecting fatigue for a period of time after a hospital stay and not recovering to baseline immediately.

Whenever possible, instructions about red flags, such as changes in blood sugar, should be coupled with interventions the patient can initiate based on previous instructions from the physician, such as a sliding scale for insulin administration, rather than sitting next to the telephone, waiting for a callback from the physician's office to provide instructions. This will empower the patient and allow for more rapid intervention, which will decrease the likelihood the patient will need emergency care.

When preparing a patient for discharge, particularly an older person with multiple medical problems, sit down and take the time to plan how the patient and her caregiver(s) will address various needs that must be met at home.

Instead of only providing a written confirmation of a follow-up appointment with a community-based care provider, ask if the patient knows where the office is. Ask how he will get to the appointment. His wife may not drive, and his condition may not allow him to drive safely. We had a patient who was admitted to the hospital because he didn't have a car or a reliable ride and couldn't afford daily cab fare to the wound clinic for care that was necessary to save his foot.

Anticipating Needs

Plan for the needs listed below. Ask the patient how he will:

  • organize and take his medications correctly;

  • get any new medicines or refills;

  • get any equipment or special supplies needed for his care (e.g., durable medical equipment, dressing supplies, nutritional supplements);

  • prepare meals and buy fresh food, with particular emphasis on any special medical dietary requirements;

  • get in and out of bed or a chair at home (remembering home furniture is more plush and less likely to have arm rests or hand rails for assistance than furniture in a hospital or skilled nursing facility);

  • get dressed and undressed;

  • go to the bathroom;

  • make telephone calls or otherwise get help if he needs it (e.g., ring a bell, a wireless communication device inside the house or one that summons emergency medical services with the push of a button); and

  • get out of the house if there is an emergency, such as a fire.

If the patient cannot articulate these plans, be sure to go over them in detail with his designated caregiver. Going through this list may help caregivers realize there is a lot more to caring for a family member at home than they may have realized, and it may help you trigger a referral for home health services that can prevent a discharge failure and readmission or a referral for short-term rehabilitation.

Good Communication

Professional-to-professional communication is essential for safe transitions to the community. Whether the transition is between shifts, units in the hospital or care settings such as home discharge, communication failures have been found as the root cause in more than 60 percent of events that involve death or serious physical or psychological injury or near misses reported to the Joint Commission.6The SHM checklist also includes information that should be provided to community-based providers; don't forget about the home health agency.1Think about all the information an institution-based nurse uses to formulate a plan of care and how bare bones the required transfer form is (typically listing diagnoses and medications only).

In addition to the information provided to the patient and caregiver, provide the information below to the home health nurse. These may all be included in the standard discharge summary; HIPAA rules allow hospitals to share this information to ensure safety and provide for continuity of care:

  • reason for hospitalization;

  • key findings and test results, any pending studies that will require follow-up, and any tests or studies scheduled after discharge (particularly INR and medical imaging);

  • final primary and secondary diagnoses (if infection, include organism from culture results so the home care agency can take any necessary precautions);

  • brief summary of hospital stay;

  • functional and cognitive status at discharge, and any prescribed limitations;

  • need for home-based or outpatient therapies (physical, occupational, speech);

  • 24/7 contact number of person at the hospital who is familiar with the patient; and

  • resuscitation status.

Environmental Risks

While it's difficult for an institution-based nurse to evaluate the home environment, it's important to talk about safety features in the home before discharge day so a caregiver can make any necessary adjustments before the patient returns. While all homes should have smoke detectors, adequate lighting and non-skid rugs, there are other features more important for individuals who are sick or injured. Think particularly about risks to patients who may lose their sense of balance because of a drop in blood pressure with standing, weakness, medications or deconditioning from illness, or changes in gait or walkig related to orthopedic or neurologic injuries or surgery.

The CDC issued a report on fall injuries in the general population in March 2008.7About 6 million adults age 65 or older (16 percent) reported a fall in the previous 3 months, and almost 2 million of those were injured to the extent they had to visit a doctor or restrict their activities for at least a day. If one in six seniors in the general population falls every 3 months, we can only imagine how much more likely falls are in compromised seniors who have just come home from a hospital stay, ED visit or skilled nursing facility admission.

To reduce fall risk, explore these home features before discharge. Are they present, can they be added or can the patient avoid these risky situations?8

  • Are safety rails present in showers and tubs and a seat for resting while bathing (or an alternative for bathing until it is safe to get into the tub/shower)?

    • Is a raised toilet seat or grab bars beside the toilet accessible? (You may want to remove a towel rack to reduce the risk someone would think it could hold their weight and prevent a fall.)

    • Are there sturdy railings on stairs? (Don't forget stairs leading up to the door from the outside or whether a ramp is needed.)

    • Are bathroom and kitchen floors protected with non-slip floor coverings, and are scatter rugs removed throughout the home?

    • Can furniture be moved to allow for a clear path for the patient to walk, particularly if a walker is needed?

    • Are lights for hallways and stairs bright and are switches easily accessible at the top and bottom of a staircase and both ends of the hall?

    • Can the patient turn doorknobs to get out of a room, the bathroom, or the house if necessary?

    Also ask the caregiver and patient about risks that may be present if the patient needs to get up during the night and go to the bathroom. How is the lighting? Is furniture in the way? Does the person have to go down a hallway? Up or down stairs? Work with them to reduce the risks; it may be as simple as setting up night lights, or a commode next to the bed may be the safest option.

    Nurses Are Key

    The pressure is on from all sides. Hospitals want to reduce length of stay, patients want to recover in their own homes and everyone is trying to save money. By planning in advance, working with patients and their families and coordinating with community-based care providers, nurses can improve the quality of patient care, reduce the risk for complications, and keep patients healthy and out of the hospital. That will increase everyone's satisfaction.


    1. Halasyamani, L., et al. (2006). Transition of care for hospitalized elderly patients: Development of a discharge checklist for hospitals. Journal of Hospital Medicine, 1(6), 354-360.

    2. Coleman, E., et al. (2004). Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. Journal of the American Geriatrics Society, 52(11), 1817-1825.

    3. Coleman, E., et al. (2004). Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39(5), 1449-1465.

    4. California Association for Health Care Services at Home. (2007, Sept. 7). Homebound status and Medicare.

    5. Coleman, E., et al. (2006). The care transitions intervention: Results of a randomized, controlled trial. Archives of Internal Medicine, 166(17), 1822-1828.

    6. Hughes, R., & Clancy, C. (2007). Improving the complex nature of care transitions. Journal of Nursing Care and Quality, 22(4), 289-292.

    7. CDC. (2008). Self-reported falls and fall-related injuries among persons aged ³65 years - United States, 2006. Retrieved June 13, 2008 from the World Wide Web:

    8. Carroll, P. (2004). Treating and preventing injuries. In, What nurses know and doctors don't have time to tell you (pp. 182-188). New York: Perigee.

    Patricia Carroll is quality management coordinator at Franciscan Home Care and Hospice Care and the owner and consultant of Educational Medical Consultants, Meriden, CT.


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