Bringing a parent or spouse home from the hospital is a relief, but it often comes with a stack of papers, new medications and a list of appointments. The weeks right after discharge are a time when things can slip through the cracks. A little planning goes a long way.
Here's a practical checklist for families in Salt Lake County, plus how transitional care at home can help.
Before You Leave the Hospital
Ask the discharge team these questions while you're still there. Write the answers down or ask for them in writing.
What was the main reason for the hospital stay, and what's the plan now?
Which medications are new, which changed, and which should be stopped?
Which follow-up appointments are needed, and with whom?
Are any tests or lab work due after discharge?
What warning signs mean we should call a provider, and which mean we should call 911?
Is any equipment or home help being arranged, and who is arranging it?
If your loved one is going to assisted living or memory care instead of a private home, make sure the community has a copy of the discharge paperwork too.
The First 48 Hours at Home
The first couple of days set the tone for recovery.
Fill new prescriptions right away. Don't wait until the old supply runs out.
Gather every medication in one place, including over-the-counter drugs and supplements, and compare them against the discharge list.
Set up the space. Clear walkways, add night lights and keep often-used items within reach.
Plan who is on call. Decide which family member checks in each day and who handles appointments.
Call the primary care provider's office to let them know about the hospital stay and schedule follow-up.
Medications: The Most Common Trouble Spot
Medication changes are one of the biggest sources of confusion after a hospital stay. A patient may come home with a new prescription that replaces an old one, but both bottles are still in the cabinet.
A careful medication review, sometimes called medication reconciliation, compares what the hospital prescribed with what the patient actually has at home. During a Dvora transitional care visit, our physician or nurse practitioner goes through each medication with the patient and family, flags duplicates or conflicts, and makes sure everyone understands the plan.
Follow-Up Care
Most discharge plans include a follow-up visit with a primary care provider, plus specialist visits or tests. For many older adults, getting to those appointments is the hard part, especially right after a hospital stay.
That's where house calls help. Dvora's physician and nurse practitioner can do follow-up visits at home, review the discharge instructions, check on symptoms and coordinate with the patient's specialists. Medicare covers transitional care management for the 30 days after a qualifying discharge, and the usual cost sharing may apply. Learn more on our Medicare and house calls page.
Warning Signs to Watch For
Your discharge papers should list the specific warning signs for your loved one's condition. Keep that list somewhere easy to see, like the refrigerator. In general, call a provider if you notice new or worsening symptoms, confusion that's new, a fever, trouble keeping food or medications down, or a wound that looks worse. For chest pain, severe trouble breathing, or signs of a stroke, call 911.
When Ongoing Care Makes Sense
For some patients, the hospital stay is a sign that they need more regular support. If your loved one has several long-term conditions, chronic care management adds monthly care planning and coordination. Ongoing in-home primary care can take over routine checkups and sick visits so the patient doesn't have to travel. If serious illness is part of the picture, palliative care can focus on comfort and symptom relief.
Transitional Care Across Salt Lake County
Dvora Healthcare provides transitional care visits throughout the county, including Salt Lake City, West Valley City, Taylorsville, South Jordan, Riverton, Herriman and Midvale. See all the cities we serve on our service areas page.
Frequently Asked Questions
What is transitional care?
Transitional care is follow-up care in the weeks after someone leaves a hospital, rehab facility or skilled nursing facility. It includes a medication review, a follow-up visit and coordination with the patient's other providers.
Does Medicare cover transitional care?
Yes. Medicare covers transitional care management for the 30 days after a qualifying discharge. The usual Part B deductible and coinsurance may apply. Dvora accepts Medicare and Medicare Advantage; call us to check your plan.
Can a follow-up visit happen at home or in assisted living?
Yes. Dvora's physician and nurse practitioner see patients in private homes, assisted living, memory care and independent living communities across Salt Lake County.
Is transitional care the same as home health?
No. Home health is skilled nursing or therapy from a home health agency. Transitional care from Dvora is follow-up medical care from a physician or nurse practitioner. Some patients have both.
How do we set up a visit after discharge?
Call us at (801) 407-9409 or request care online. Hospital and facility staff can use our Refer a Patient page.