A Step-by-Step Overview of the Transition Home

Leaving the hospital is often a relief—but getting your loved one safely settled at home can be challenging.

Medications may have changed. New appointments may be needed. Your loved one may be weaker than before hospitalization, and your family may suddenly be responsible for care that you weren’t expecting.

A successful hospital-to-home transition starts with a plan.

Recommendations involving patients and caregivers in discharge planning and making sure they understand medications, follow-up care, warning signs, test results, and what to do if problems occur.

Step 1: Before Leaving the Hospital

Make sure you understand:

• Your loved one’s diagnosis
• What treatment was provided
• What medications changed
• Follow-up appointments
• Activity and dietary restrictions
• Warning signs to watch for
• Who to contact with questions
• What services or equipment are needed at home

Don’t leave with unanswered questions.

Step 2: Prepare the Home

Before your loved one arrives, make the home as safe and accessible as possible.

Consider:

• Clear walking paths
• Bathroom safety
• A safe sleeping area
• Walker, wheelchair, or other equipment
• Medications
• Food and water
• Phone access
• Transportation for appointments

MedlinePlus recommends preparing the home and arranging necessary equipment and assistance before or soon after discharge.

Step 3: Review Every Medication

Create one current medication list.

Include:

• Medication name
• Dose
• When to take it
• What it is for
• New medications
• Medications that were stopped or changed

If the discharge instructions conflict with an older medication list, ask the healthcare team or pharmacist for clarification rather than guessing.

Step 4: Confirm Follow-Up Care

Make sure you know:

• Who your loved one needs to see
• When the appointment is
• Where it is located
• Who is providing transportation
• Whether laboratory tests or imaging are needed
• Whether any test results are still pending

Identify follow-up appointments and pending test results as important parts of the hospital-to-home transition.

Step 5: Make Sure Home Services Are Arranged

If your loved one needs home health, therapy, nursing, medical equipment, or other assistance, confirm that those services have actually been arranged.

Don’t assume that discussing a service means it has been scheduled.

Illinois’ Department on Aging provides caregiver resources specifically addressing transitions from the hospital to home, including home care and durable medical equipment.

Step 6: Watch for Changes

Ask the healthcare team:

“What specific symptoms should we watch for, and who should we call if something changes?”

Pay attention to new or worsening symptoms, medication problems, falls, confusion, difficulty breathing, or other changes identified by the healthcare team.

If you believe your loved one is experiencing a medical emergency, call 911.

Step 7: Check In During the First Few Days

Don’t wait weeks to discover that something isn’t working.

Ask:

• Are medications being taken correctly?
• Are appointments arranged?
• Has home health started?
• Is the equipment working?
• Can my loved one safely manage daily activities?
• Are symptoms improving?
• Do we need additional help?

Hospital-to-home transitions can be complicated, and patients and caregivers may suddenly become responsible for coordinating medications, appointments, services, and ongoing care.

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What If Home Isn’t Working?

Sometimes your loved one needs more assistance than the family can safely provide.

That’s important information—not a failure.

If your loved one cannot safely manage at home, contact their healthcare team and discuss available options. Depending on the situation, additional home services, rehabilitation, skilled nursing, or other care arrangements may need to be considered.

In Illinois, hospitals are required to consult with a designated caregiver before discharge to the patient’s residence and provide a discharge plan describing appropriate after-care needs.

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How a Patient Advocate Can Help

Hospital-to-home transitions can be overwhelming, especially when multiple medications, providers, appointments, and care needs are involved.

Our Father Patient Advocacy can help patients and families organize information, prepare questions, navigate healthcare services, coordinate care, and better understand the next steps.

We don’t replace your healthcare providers or make medical decisions. We help you become a more informed and organized participant in your loved one’s care.

Need Help With a Hospital Transition?

Visit ourfatherpa.org and use the Contact Form, or send us a message 815-912-0202 to learn more.

You don’t have to navigate healthcare alone. You deserve an advocate.

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Related Resources

• Hospital Discharge Checklist for Family Caregivers
• What Questions Should I Ask Before My Loved One Leaves the Hospital?
• What to Do When Your Parent Comes Home From the Hospital
• What If I Don’t Think My Loved One Is Ready to Leave the Hospital?
• Polypharmacy: What Patients and Caregivers Need to Know

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Last reviewed: August 2026

Disclaimer

This information is provided for general educational purposes only and is not medical advice, diagnosis, or treatment. Every patient’s situation is different. Follow the discharge instructions provided by your healthcare team and contact an appropriate healthcare professional with questions about your specific situation.

If your loved one is experiencing a medical emergency, call 911 or seek emergency medical attention.