When to Refer a Patient for Non-Medical Home Care After Hospital Discharge

A safe discharge does not end when a patient leaves the hospital.

For some patients, the clinical plan may be clear, but everyday life at home creates another challenge: Who will help with bathing, dressing, meals, mobility, supervision, transportation, or other daily activities?

Discharge planning may include evaluating both healthcare services and non-healthcare support a patient may need after leaving the hospital.

Signs a Patient May Need Additional Support at Home

Healthcare professionals and families may want to explore non-medical home care when a patient:

• Has difficulty safely completing activities of daily living, such as bathing, dressing, grooming, or toileting.

• Needs assistance with meals, light household tasks, errands, or transportation.

• Has limited mobility and may need help navigating everyday routines.

• Will spend significant periods at home without reliable family or caregiver support.

• Needs supervision or companionship because of cognitive or functional limitations.

• Has family caregivers who cannot consistently provide the amount of assistance required.

Older adults may require particular attention during care transitions. Hospitalization can contribute to decreased mobility and functional decline, while the period following discharge may present additional fall and safety concerns.

Home Care and Home Health Are Not the Same

Determining what kind of support the patient needs is important.

Medicare home health can include medically necessary intermittent skilled nursing, physical therapy, occupational therapy, and speech-language pathology when eligibility requirements are met.

Non-medical home care instead focuses on everyday support and personal assistance.

In some situations, a patient may need both skilled home health services and additional non-medical assistance.

Five Questions to Ask Before Discharge

1. Can the patient safely manage everyday activities at home?

• Consider bathing, dressing, grooming, toileting, meals, mobility, and other routine activities.

2. Who will actually be available to help?

• A family member living nearby does not necessarily mean someone will be available throughout the day.

3. Can family caregivers realistically provide the required assistance?

• Consider work schedules, transportation, other caregiving responsibilities, and the physical demands of providing care.

4. Are there mobility or home-safety concerns?

• Potential hazards can include poor lighting, clutter, loose rugs, stairs, and bathrooms that are difficult to navigate safely.

5. Does the patient need skilled care, non-medical assistance, or both?

• Understanding the difference can help families and care teams build a more realistic transition plan.

Planning for the Transition Home in Southwest Georgia

For patients returning home in Albany and surrounding Southwest Georgia communities, planning should begin before the patient arrives home, particularly when family support, transportation, mobility, or access to community services may be limited.

Identifying those gaps early gives the patient, family, and care team more time to develop a realistic plan for the transition home.

For Healthcare Professionals

South West Georgia Homecare is developing healthcare-professional referral infrastructure to support care transitions and access to non-medical home care across Southwest Georgia.

Healthcare professionals can explore SWGA's referral resources and planned care-transition workflow through the Healthcare Professionals section of our website.

Families and professionals can also use the SWGA Healthcare Navigator to discover participating healthcare providers and resources serving Southwest Georgia.