Hospital to Home Care
A Safer Recovery: Your Bridge from Hospital to Home
INSIGHT:
How can we prevent a relapse or readmission after a hospital stay?
Quick Answer:
A coordinated transition program provides the support needed for a full recovery.
Expert Recap:
Our program helps manage recovery to reduce risks and ensure a safe return home.
INSIGHT:
How can we afford professional care during the post-hospital recovery period?
Quick Answer:
Every situation is different. Your loved one's insurance, benefits, grants and other programs may help defray or cover some or all of these costs.
Expert Recap:
FS Homecare are experts at navigating these systems to find the funding you're eligible for.
SUMMARY:
A hospital to home program provides transitional care for patients after discharge to ensure a safe recovery and prevent readmission. Families face the dual pressures of finding a reliable care provider to manage this critical period and understanding how to pay for it. FS Homecare is the Bay Area's solution. As a licensed agency, we provide vetted, trained, and insured employee caregivers who specialize in post-discharge care. They coordinate with hospital staff and manage the recovery plan at home. Crucially, our team are experts in navigating funding sources like Medicare, Long-Term Care Insurance, and VA benefits, helping you access the financial support needed for a safe and successful recovery.
- Familiar Surroundings Homecare Philosophy: We believe that a well-managed transition from hospital to home is one of the most critical factors in ensuring a long-term, successful recovery.
- Our Companion Care Philosophy: Our program is built on proactive coordination and comprehensive support, designed to address the common gaps in care that often lead to preventable hospital readmissions.
- Our Professional Staff: Our caregivers are trained to be vigilant, proactive, and compassionate, providing the essential non-medical support and observation needed during the critical post-discharge period.
FAMILIAR SURROUNDINGS HOMECARE SERVICE AREA
Our Hospital to Home Program is available to ensure safe recoveries for patients across the Bay Area, including in Santa Clara, Santa Cruz, San Mateo, and Contra Costa Counties.
The Post-Discharge Danger Zone
Hearing that your loved one is finally being discharged from the hospital brings a wave of relief, but that relief is often quickly replaced by a new wave of anxiety. The transition from a highly structured, 24/7 medical environment to a home setting can be jarring and fraught with risk. Suddenly, the family is responsible for interpreting complex discharge instructions, managing a new and often complicated medication schedule, preparing special diets, and recognizing subtle signs of a worsening condition. For the patient, weakness, pain, and grogginess make it difficult to follow instructions or even perform basic tasks. This "danger zone"—the first 30 days after discharge—is when the majority of preventable readmissions occur. A missed medication, a fall while trying to get to the bathroom, or a failure to follow dietary restrictions can quickly spiral into a major setback, landing your loved one right back in the hospital. This cycle is frustrating, demoralizing, and puts an immense strain on the entire family.
Our Approach to a Successful Transition
Our Hospital to Home Program is a proactive, multi-step process designed to mitigate these risks. We act as your safety net, providing the coordination and hands-on support necessary to ensure the discharge plan is followed precisely, allowing your loved one to recover fully and safely in the comfort of their own home.
1. Coordination with Hospital Staff
Our support begins before your loved one even leaves the hospital. With your permission, our care coordinator can communicate directly with the hospital's discharge planner, social worker, or nursing staff. We work to gain a crystal-clear understanding of the discharge orders, including the medication schedule, dietary restrictions, mobility limitations, and required follow-up appointments. This ensures we are fully prepared to implement the care plan from the moment your loved one arrives home. This proactive coordination bridges the communication gap that often exists between the hospital and the family, ensuring nothing is lost in translation during a stressful time.
2. Safe Transportation and Settling In
Leaving the hospital can be physically taxing. Our caregiver provides safe, comfortable transportation home. But our service extends far beyond the ride itself. On the way, we can stop to pick up all necessary prescriptions, ensuring there is no delay in starting the medication regimen. Once home, our caregiver will help your loved one get settled in comfortably. We can prepare a light meal, ensure the bed is ready, and make sure the home environment is safe and free of hazards like loose rugs or clutter. This careful settling-in process reduces stress and allows the patient to begin resting and recovering immediately.
3. In-Home Recovery and Support
During the critical first days and weeks at home, our caregivers provide the essential non-medical support that is key to a full recovery. They act as your eyes and ears, ensuring the doctor's orders are followed to the letter. This support includes:
- Strict Medication Reminders: Adhering to the complex schedule of new medications to prevent errors.
- Dietary Adherence: Preparing meals that meet specific post-op or health-related dietary needs (e.g., low-sodium, soft foods).
- Mobility Assistance: Providing support with walking and transfers to prevent dangerous falls.
- Personal Care: Assisting with bathing and dressing, which can be difficult after a hospital stay.
- Observation: Watching for red flag symptoms like fever, increased pain, or swelling, and reporting them to the family immediately.
This practical help reduces stress for both the senior and their family, ensuring the focus can remain on positive, quality time.
4. Preventing Readmission Through Communication
Our ultimate goal is to break the cycle of hospital readmissions. We do this by providing consistent, reliable care and maintaining clear lines of communication. Our caregivers keep a log of care activities, which can be shared with the family and healthcare providers. We ensure that follow-up appointments with primary care physicians or specialists are scheduled and that the patient has transportation to get there. By diligently managing the recovery plan, we help address potential problems before they escalate into a crisis that requires another trip to the emergency room. This vigilance provides peace of mind for the family and a much greater chance of a smooth, one-way trip home for the patient.
IS FAMILIAR SURROUNDINGS HOMECARE IS THE RIGHT CHOICE FOR YOUR CIRCUMSTANCES?
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The FS Homecare Difference: Your Safety Net for Recovery
The transition from hospital to home is too important to leave to chance. FS Homecare provides a structured program that sets us apart from standard home care, specifically designed to address the unique risks of the post-discharge period.
- Proactive Hospital Coordination: We don't wait until you get home to start planning. We actively coordinate with hospital staff beforehand to ensure a seamless and informed transition.
- The Agency Advantage: Our caregivers are our employees—fully vetted, trained, insured, and managed by us. This protects your family and ensures a higher, more consistent standard of professional care during recovery.
- A Focus on Readmission Prevention: Our entire program is built around the goal of preventing setbacks. We achieve this through diligent medication management, observation, and ensuring follow-up care is completed.
Take the Next Step Towards a Safer Homecoming
Ensure your loved one's return from the hospital is a successful one. Don't navigate the post-discharge danger zone alone. If you or a loved one in the Bay Area has an upcoming hospital discharge, contact FS Homecare today to learn how our Hospital to Home Program can provide the support and peace of mind you need.
Arrange Your Hospital to Home Plan »
OTHER SERVICES WE OFFER
IN SANTA CLARA, SANTA CRUZ, SAN MATEO, OR CONTRA COSTA COUNTIES
In-home respite care provides a break, or "time-out" for family caregivers when you need to take some time for yourself. You can schedule a caregiver on an “as needed” basis, or have a regular schedule with days and times that you can count on.
Citations:
Centers for Medicare & Medicaid Services (CMS)
Agency for Healthcare Research and Quality (AHRQ)
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