Hospital-to-home care
A safer recovery starts the day you come home.
The weeks after a hospital or rehab stay are when complications are most likely. We coordinate with discharge planners, get a nurse to the house quickly and provide the hands-on help that keeps recovery on track.
Nurse visit within 24 hoursOf discharge, in most cases
What's included
One coordinated plan from bedside to home
Nearly one in five older adults is readmitted within 30 days of leaving the hospital — often because of medication mix-ups, missed follow-ups or a fall at home. Our transitional care program is designed to close those gaps from the very first day.
Call us before discharge
Ask the hospital case manager to send a referral to Sample Home Health, or call us and we'll handle it for you.
- Discharge coordination with hospital and rehab case managers.
- A nurse visit within 24 hours to review orders and vitals.
- Medication reconciliation to catch duplicates and conflicts.
- Home safety check with fall-prevention recommendations.
- Follow-up appointment scheduling and transportation.
- Aide support for bathing, meals and mobility while strength returns.
- Warning-sign education so families know when to call.
The first 30 days
What recovery with us looks like
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Before
Discharge planning
We review orders with the hospital and arrange equipment, medications and the first visit.
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Day 1
Nurse at home
A nurse checks vitals, reconciles medications and walks the family through the plan.
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Week 1–2
Hands-on support
Nurse visits and aide shifts as needed while strength and confidence return.
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Day 30
Back on track
We taper visits as recovery goals are met and adjust long-term support if needed.
Questions
Hospital-to-home FAQs
Can I choose my home health agency at discharge?
Yes. Medicare patients have the right to choose their home health agency. Just tell the hospital case manager you'd like Sample Home Health, and we'll coordinate the rest.
Is transitional care covered by Medicare?
Skilled nursing and therapy visits after a hospital stay are typically covered when your loved one is homebound. Extra aide hours can be added privately or through long-term care insurance.
What if we're already home?
It's not too late. Call us and we'll reach out to your doctor for orders. Many families start care a few days after discharge when they realize they need more help.
Related services
Often paired with hospital-to-home care
Skilled Nursing
RN and LPN visits for medication management, wound care and chronic condition support.
Learn morePersonal Care
Gentle, dignified help with bathing, dressing, grooming and moving safely around the house.
Learn morePaying for Care
See how Medicare, Medicaid, VA benefits and long-term care insurance can help cover costs.
Learn moreDischarge coming up? Let's plan it together.
Call us today. We'll coordinate with the hospital so your loved one comes home to the support they need.