Discharge Plan for Success at Home

7 Tips to Help YOU Transition from the Hospital or Rehab Center to Home and Avoid an Unnecessary Readmission in the First 30 Days


The majority of health conditions we treat at Boca Home Care are: Cardiac, COPD, Diabetes, and Orthopedic (Hip, Knee, or Shoulder), all which may be compounded by Dementia. 

Once the Hospital or Rehab Discharge Planner reviews your Discharge Plan with you and hopefully your spouse or other family member, it is up to the patient to best manage their condition and/or recovery. We strongly recommend someone be with you when you are being discharged.


The Seven Most Important Things You Can Do for Your Progress and to Guard Against Preventable Readmissions are:

  • Get Educated About Your Medical Condition – Ask The Doctor and Nurses What You Want to Know, What You are Curious About.

  • Involve Your Family, Especially if You live Alone. Let Them Help You with Medications and Appointments as well as hiring In-Home Care if needed.

  • Make and Keep Your Follow Up Doctor’s Appointment within 7 Days of Discharge.  

  • Order the Medications and Pick them up the Same Day You are Discharged.

  • Ask questions about New Medications (names, purpose, dose, time and with or without food)

  • Safety Proof Your Home to Help Prevent Falls & Fractures

  • Ask About Your Dietary, Nutritional and Physical Activity/Exercise Needs or Restrictions.

If you live alone or your spouse is unable to assist you fully then consider hiring a caregiver/aide even for a short period of time. The Caregiver will assist with your personal care, safety, cooking, shopping and getting you to the Doctor for appointments.

 This is especially important if you, the patient are also the primary caregiver in the home to an impaired loved one. This is not the time to be a hero as the first few weeks out of the hospital or rehab center are when you are particularly vulnerable to re-hospitalization.

Remember, once you return home, the responsibility for your improvement is shared between you, your family, and Your Medicare Home Health Professionals.