The family caregiver's role during a transition from hospital to home

This guide is for family caregivers and the clinicians who support older adults moving from hospital to home. It explains how to take part in the discharge plan, share what is happening at home and work with the care team during early follow-up.

1. Take part in the discharge plan

Families often end up coordinating care without preparation or support. In testimony to the U.S. Senate Special Committee on Aging, geriatrician Eric Coleman described patients and family caregivers as "silent care coordinators" who perform significant coordination by default. He also said these challenges can be overcome.

The caregiver's first role is to be included while the plan is being made. Ask the team to explain who is coordinating the transition, what follow-up is planned and how the hospital will communicate with the primary care provider. CMS's Hospital Readmissions Reduction Program encourages hospitals to improve communication and coordination and engage patients and caregivers in discharge plans.

A systematic review of transitional care models for frail older adults suggests that shared decision making, caregiver involvement and a small team with a coordinator may improve a model's chances of success. For families, that means making sure the plan reflects what the older adult wants and what support the caregiver can provide. The review also found that models combining planning before discharge with intensive follow-up afterward can reduce readmissions and emergency department visits.

2. Make the first week part of the plan

The first days at home deserve attention before discharge. A study protocol on follow-up after discharge from a geriatric ward notes that older adults with multiple conditions, several medications or functional impairments face increased risk of acute admission and readmission. It reports that readmission rates among geriatric patients are high, especially in the first week after discharge.

Before leaving the hospital, caregivers can ask the team to state who will make contact after discharge and what the follow-up plan includes. If the plan is unclear, ask for the name of the person or service coordinating it. When health decisions come up, discuss them with the older adult's own doctor.

3. Know what transitional nursing support can include

The Transitional Care Model described by Mary Naylor uses advanced practice registered nurses who meet patients during hospitalization, coordinate discharge plans, visit the home within 24 hours and provide intensive follow-up for about two to three months. That gives the caregiver a defined contact for questions about carrying out the transition plan.

In testimony to the U.S. Senate Committee on Finance, Naylor described regular nurse home visits and telephone support available seven days a week for an average of two months after discharge. The nurse may also accompany the patient to the first follow-up visit to help maintain continuity between hospital and primary care. Caregivers can ask whether this kind of support is available and how to reach the nurse between visits.

A review of transitional care models for frail older adults examined eight programs that combined a home or clinic visit with telephone follow-up. Four reported significant reductions in readmissions or emergency department visits. The review's findings describe programs, not a promise of the same result for every patient.

4. Use home visits to show how care works in real life

A home visit can help clinicians see needs that are hard to judge in a hospital or clinic. An account from UAB Medicine describes how seeing patients at home can reveal problems caregivers face with disease management, emotional issues and personal care. The clinician can take in information about the patient and the home situation at once.

Caregivers can use a planned visit to describe what is difficult in the day-to-day routine and where the older adult needs help. That gives the care team a clearer picture of whether the discharge plan fits the actual home situation. Share concerns plainly, including when the caregiver's own physical or emotional capacity affects what support is workable.

5. Match the plan to the caregiver's capacity

A care plan depends on the people who will carry it out. A study of hospital-at-home and hospital-at-nursing-home care for respiratory infections found that older patients and caregivers generally viewed those options as positive alternatives to hospital admission, with high overall satisfaction. The authors also reported that feasibility depended on patients' and caregivers' physical and emotional circumstances.

That finding is a reminder to discuss capacity when a care team offers a home based option or sets up follow-up. Explain what help is available and what the caregiver can realistically manage. The care team can then consider those circumstances as part of a person-centered plan.

6. Keep the handoff connected to ongoing care

Discharge is one handoff in a longer period of care. The Transitional Care Model links the hospital plan with primary care through nurse follow-up, while the review of transitional care models points to a small team and coordinator as useful elements. Caregivers can help by knowing which clinician or coordinator is the point of contact after the hospital team steps back.

For practice teams, the caregiver's observations are part of understanding whether the plan is working at home. Agree on how follow-up will happen and who should receive updates. Keep the patient involved in those conversations so the plan remains person-centered.

This page is general education only. It is not medical advice. Talk with your own doctor about your health.

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