Geriatrics
Best practices for maintaining continuity of care during transitions from hospital to home.
A practical, evidence-informed guide for patients, families, and clinicians to ensure seamless continuity of care when older adults move from hospital settings back to their homes, with attention to medications, follow-ups, and safety.
July 28, 2025 - 3 min Read
When an older adult leaves the hospital, the transition is a critical moment for safety, medication accuracy, and ongoing disease management. Care teams often focus on discharge instructions, but real continuity hinges on clear communication, reliable documentation, and timely follow-up. Families and caregivers play a central role in bridging hospital and home, translating medical language into practical routines that support recovery. Effective transitions require planning that begins before discharge and extends into the first weeks at home, with attention to potential pitfalls such as forgotten prescriptions, missed appointments, and gaps in home supports. A well-structured handoff reduces readmissions and preserves independence.
A successful hospital-to-home transition begins with a comprehensive discharge plan coordinated among the hospital team, primary care, and community services. This plan should include up-to-date medication lists, a clear schedule of follow-up visits, and a practical summary of diagnoses and treatment goals. Shared access to the care plan by all stakeholders minimizes confusion and clarifies who is responsible for each task. When possible, a designated care navigator or transition coordinator can ensure that the patient’s home environment is prepared, necessary equipment is arranged, and that caregivers know whom to contact with questions or concerns. The goal is a smooth, predictable process rather than a series of isolated instructions.
Family involvement and caregiver support strengthen continuity and safety.
Medication reconciliation at discharge is essential for preventing adverse drug events during the first weeks home. Pharmacists can verify each prescribed drug against the patient’s prior regimen, allergies, and current lab results, then communicate potential interactions to the care team. Written pill organizers, teach-back demonstrations, and simplified dosing schedules help patients and caregivers adhere to the regimen. Providing a printed, easy-to-read medication list, along with a digital copy accessible by clinicians, reduces errors and supports monitoring. Patients should be instructed to report side effects promptly and to keep a current list of all medications, vitamins, and over-the-counter products.
Care coordination after discharge should include a scheduled post-discharge check-in, ideally within one week, with a nurse or care coordinator. This touchpoint serves to confirm that the patient is following the discharge plan, address any new symptoms, and verify that home supports are functioning. Effective coordination also involves arranging timely follow-up appointments with primary care and any specialists, as well as testing or imaging studies if indicated. For some patients, home health services, physical therapy, or social work support can reinforce recovery and address barriers such as transportation or caregiver strain.
Clear communication channels reduce anxiety and misinterpretations.
Family members often become informal care coordinators, tracking appointments, medications, and daily routines. To empower them, clinicians should provide concise instructions written in plain language, offer demonstrations of wound care or mobility aids, and ensure access to translation or interpretation when needed. Encouraging caregivers to maintain a simple daily log of symptoms, pain levels, meals, and activity helps detect early deterioration. These records should be shared with the patient’s clinicians so that any necessary adjustments to therapy or support services can be made quickly. Respect for caregiver time and limits remains essential throughout the process.
Telehealth and remote monitoring can extend the reach of transitional care, especially for older adults with chronic diseases. Virtual visits reduce travel burdens while maintaining oversight of symptoms and medication changes. Remote monitoring devices—such as blood pressure cuffs or glucose meters—can feed data to clinicians, enabling timely intervention if readings deviate from baseline. It is important to ensure patient privacy and user-friendly interfaces, with technical support available to patients and caregivers. Regular, proactive outreach helps prevent emergencies and reinforces a sense of connection to the care team.
Practical supports around home safety and daily function are essential.
Clear, plain-language communication is foundational to continuity of care. Discharge instructions should avoid medical jargon, include concrete routines, and specify who to contact for urgent versus non-urgent questions. Written summaries, verbal iterations, and teach-back confirm understanding. Visual aids or checklists can reinforce key points such as medication timing, activity restrictions, and signs that require medical attention. Clinicians should also document conversation highlights, patient preferences, and anticipated challenges so the entire team remains aligned as the patient transitions home.
Access to reliable transportation and flexible scheduling is often the difference between keeping or missing follow-up care. Homebound patients or those with weaker mobility may benefit from accompanying visits by home health professionals or telehealth options. Scheduling appointments in the same facility or using integrated electronic health records helps ensure that information flows seamlessly between hospital, primary care, and specialists. Coordinated reminders and transportation arrangements reduce no-show rates and foster continuity, while keeping the patient’s preferences at the center of planning.
Long-term success depends on ongoing monitoring and adjustment.
The home environment should be assessed and adapted to reduce fall risk, improve medication safety, and support functional independence. Simple modifications—secure lighting, non-slip mats, railings, and clutter reduction—can have outsized effects on safety. In addition, ensuring proper equipment such as assistive devices, walkers, or shower seats is crucial. A home safety assessment, ideally conducted by a qualified professional, helps identify hazards and develop a practical plan. Families should be involved in reinforcing safe routines, practicing transfers, and understanding the correct use of any medical devices.
Functional support extends beyond safety; it includes nutrition, activity, and sleep routines that promote healing. Clinicians can recommend tailored meal plans, hydration strategies, and activity regimens that accommodate fatigue and medical restrictions. Sleep quality impacts recovery, mood, and adherence to treatment. Encouraging light physical activity, within medical limits, helps maintain strength and balance. Regular meals, timely medications, and a predictable daily structure create a stable foundation for recovery and reduce confusion for patients and caregivers alike.
Ongoing monitoring after discharge should balance proactive surveillance with respecting patient autonomy. Regular primary care visits are essential to track blood pressure, glucose control, renal function, and other vital parameters. Shared decision-making around treatment goals fosters engagement and adherence, especially when plans need adjustment due to evolving health status. Clinicians can implement concise, patient-friendly progress notes that summarize what has changed and why. Families should be kept informed about evolving plans so they can adapt routines, manage medications, and seek timely help if symptoms worsen or new risks appear.
A culture of continuous improvement in transitions means learning from each patient’s experience. Hospitals can evaluate discharge processes, measure readmission rates, and solicit feedback from patients and caregivers to refine handoffs. Community programs and primary care practices can align their policies to support smoother transfers, including standardized forms, better access to specialists, and integrated social services. By investing in education for clinicians and families, healthcare systems create resilient pathways that protect health, preserve independence, and reduce stress during a vulnerable period of recovery.
