Are You Prepared for a Loved One’s Care Transition?

Without a doubt, one of the hardest things for families to do is help an aging loved one transition back home from a hospital or rehab center stay – and the stakes are huge. Many older adults who leave the hospital will be readmitted within 30 days for a variety of reasons, such as falls, non-adherence to medication regimens, or a lack of follow-up care.

The good news is that most readmissions are preventable. I always recommend families begin coordinating the transition to home as soon as their loved one is admitted to the hospital.

Here are the top 5 things families need to know about transitions:

  1. It takes a lot of appointments, emails and phone calls to coordinate care. For families that are reeling from a loved one’s sudden health event, the load can be too much to bear. Aging Life Care Professionals® can make all the difference. They help families navigate every detail of medical care, food, transportation, home modifications for safety and filling medications to get home ready for the patient after discharge. They also act as a quarterback of the entire Care Team to ensure everyone is on the same page for a seamless transition.
  2. Home may not be “home,” at least initially. Don’t assume your mom or dad will go right home after a hospital stay. It’s common for older adults to go to a rehabilitation center, “step-down unit”, or nursing home before they can return safely to their homes. About 25% of people admitted to these facilities stay only a short time (3 months or less), according to, but 90 days can feel like a long time if your loved one is isolated from family and friends. If you live far away, consider hiring a private-duty caregiver to check-in on your loved one so they have a reliable, friendly face to keep them engaged and working toward recovery.
  3. Exceptional in-home care means more than simply assisting with activities of daily living. Help with bathing, dressing, and eating are just the baseline of care. Excellent caregivers will get to know your family member’s likes and dislikes and understand how to spark their interest in hobbies, exercise, conversation and other activities that bring joy and meaning to their lives.
  4. You might not have the right caregiver fit the first time around. There may be relationship tension, just like on a first date, so you must give it time. As time goes on, if the caregiver doesn’t work out, speak up and ask your agency to find another caregiver. This is where an Aging Life Care Professional® can be a great quarterback to assist in finding a qualified caregiver. A high-quality agency will be happy to have this conversation with you and will work with you to find the right fit.
  5. It takes time to adjust to the new normal – for everyone. Give yourself grace and space to accept your family member’s physical or cognitive loss. Give them time to do the same. If you or your loved one would benefit from mental health resources, ask an Aging Life Care Professional for recommendations.

The most important thing to remember is that you don’t have to plan a home transition by yourself. Every community has resources to help you. Find Aging Life Care Professionals near you.

About the Author: Nancy Gillette is Chief Growth Officer for the HouseWorks companies, one of the largest independent in-home care companies in the nation. She has more than 20 years of experience in the home care and post-acute fields growing revenue, building strategic relationships and diversifying product offerings. View Nancy’s LinkedIn profile. Nancy spoke at the ALCA 37th Annual Conference in 2021.