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Hospital to Home Transition – How to smoothly navigate successfully and safely back home… Greg Hartwell

November 13th, 2014

Hospital to Home TransitionGreg Hartwell is the Managing Director and Founder of Homecare California. Greg is a frequent writer and guest speaker on elder care issues. For more information or questions contact him at or 650-324-2600.

“Be Prepared”. It’s the motto of the Boy Scouts of America. But its good advice for family members whose senior loved ones who have been admitted to the hospital.

A hospital admission is stressful for everyone – patient and family. And while you are understandably concerning yourself with the care and recovery of your loved one, a hospital discharge planner starts the discharge planning process the moment you are admitted. Indeed, there is barely time to catch one’s breath before they are pushing you out to the door.

In 1990, the average hospital stay for those 75+ was over 9 days. Today its about 5.5 days. Length of stay is primarily dictated by medicare or your health insurance company so consumers have little control over the timing. With the cost of a hospital bed-day ranging from $3,000-$5,000 excluding any medical care, one can understand why these organizations want to push you out as quickly as possible. And because a patient’s recovery can fluctuate from day to day, case managers can rarely give you a concrete date/time of discharge. It is not uncommon to get less than 24 hours notice. Because family members are often the adult children that work full time, it can be a frustrating process planning when you will be taking time off for discharge and post-hospitalization care.

I’ve worked with over 800 families providing assistance in their homes and a good majority of them have involved post hospitalization care. I observed that most of them waited until notified of discharge before making plans for the transition home. They didn’t know any better. And while the hospital stay is stressful, the transition home can be even more so. Medications have likely changed (sometimes dramatically), prescriptions need to be filled, sleep patterns have been disrupted such that the patient is up at night and sleeps during the day. Most importantly, capabilities have likely diminished since leaving the home. The first 72 hours upon returning home are the most important time to successfully keeping loved ones safe and prevent a bounce back to the hospital.

As a result of my experiences, I created a Hospital to Home Transition Guide to help educate families on how to prepare for the discharge and transition home. The 7-page guide is easy to read and can be used as a hands on reference during the process. It is broken down into 4 sections and an appendix.

  • Who’s Who – Knowing the Players
  • Phase I – Preparing for Discharge
  • Phase II – Discharge & The Transition Home
  • Phase III – Staying at Home
  • Appendix A – Questions to Ask When Hiring In-Home Care

If you would like a copy of the free guide, you can click here.  And of course if you have any questions, feel free to contact Greg at


  1. Jane Klein December 3, 2014

    A very important aspect of transitioning home is the understanding and management of medications. Medication errors are one of the most common reasons for preventable hospital readmissions. It’s extremely common for someone to be in a bewildered state upon discharge – especially when given new medications and prescriptions. Our unique in-home medication services lessen patient confusion and provide peace of mind for distant family members.

    In-Home Implementation of medication reconciliation and adherence Is the safest line of defense against medication errors. Just ask the doctors!


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