Hospital Discharge Home Care | San Diego

Why discharge support matters

20% of seniors are re-hospitalized within 30 days. Most of it is preventable.

The Medicare Payment Advisory Commission reports that nearly 1 in 5 senior hospital discharges results in re-admission within a month — usually for medication errors, falls, infections, or missed follow-up appointments. The single biggest factor: no skilled hands at home during the first week.

What we handle in the first 72 hours

Medication reconciliation against discharge list
Transportation home from the hospital
Home safety walkthrough (rugs, lighting, bathroom)
Meal prep aligned with new dietary restrictions
Mobility assistance & fall prevention
Follow-up appointment scheduling & rides
Daily vitals tracking (BP, weight, pain)
Direct line to your discharge planner

How it works

From discharge planning meeting to care at home.

Hospital coordination

We talk directly with your discharge planner to review needs, meds, and equipment — no faxing forms back and forth.

Pre-discharge prep

Our RN does a home visit before discharge to prep the environment and confirm equipment is in place.

Day-of handoff

Caregiver meets the patient at home (or rides with them) and starts care immediately — no gap.

Recovery support

Daily care for as long as needed — typically 2–4 weeks for post-surgical, longer for complex recoveries.

Common discharge scenarios we handle

Whatever brought them in — we've supported the road home.

Our team is built around the most common San Diego senior discharge profiles. Each gets a slightly different care plan, but all include RN oversight and the first-72-hour protocol.

Hip or knee replacement recovery
Stroke and post-stroke rehab
Cardiac procedures (CABG, stent, valve)
Pneumonia, COPD exacerbation
Fall-related fractures
UTI / sepsis recovery
Cancer treatment recovery
General weakness / failure to thrive

We work with San Diego's hospital discharge teams

Discharge planners, case managers, and hospital social workers can coordinate home care with us directly. If a discharge is being planned for your loved one, either you or their planner can call us — the family doesn't need to fill out referral paperwork to get started.

Common questions

Discharge-day questions families ask.

How much notice do you need before a hospital discharge?

Ideally 24–48 hours, but we have started same-day care for discharges as late as 4pm. The earlier we know, the more time our RN has to prep the home, coordinate with the discharge planner, and match the right caregiver — but we keep daily capacity reserved for late-notice cases.

Does Medicare pay for senior home care after hospital discharge?

Generally no. Original Medicare covers limited "home health" (skilled nursing, PT, OT) for a short period after discharge, but does not cover non-medical home care (bathing, meals, companionship, transportation). Most families pay privately, use long-term care insurance, or access VA Aid & Attendance if eligible. We bill LTC insurance directly so you don't have to wait for reimbursement.

Will you work alongside home health (Medicare PT/OT)?

Yes, and we do this every week. Home health agencies provide skilled medical visits a few times per week; we provide the daily presence between those visits — making sure the patient does their PT exercises, takes meds correctly, eats well, and stays safe. We coordinate schedules directly with the home health team.

How long do most families need care after discharge?

For a typical hip or knee replacement: 2–4 weeks of 6–8 hours daily. For stroke or cardiac recovery: 4–8 weeks, often tapering down. For frailty or "failure to thrive" discharges: usually ongoing care, since the discharge itself signals a new baseline. We reassess at day 7, day 30, and quarterly.

What if the patient resists having a caregiver in the home?

Very common after a hospital stay — many seniors associate "help" with losing independence. We introduce the caregiver as part of the recovery plan rather than as a permanent fixture, often starting with shorter shifts (4 hours) focused on practical help (meals, rides to follow-ups) rather than personal care. Most reluctant patients accept the routine within the first week.

Going home from the hospital? We can be there when they arrive.