When moving from hospital to home care, medication, abilities and responsibilities often change. This guide shows how family members can understand these changes, prepare for discharge and provide reliable support during the first few days at home.
01
Why transitions require special attention
A hospital stay interrupts the usual care provided at home. In hospital, other people take over treatment and care; upon discharge, many tasks quickly revert to everyday life at home. Such transitions require special attention because the patient’s state of health, treatment and need for support may have changed at the same time.
During the stay, medication may be started or stopped, diagnoses may be updated, therapies recommended and medical aids prescribed. At the same time, strength, mobility, orientation or independence may be different after discharge than they were before. This results in new tasks at home that did not exist before the stay.
Risks arise above all when these changes are not fully communicated to the follow-up care team: the new medication plan sits alongside the old one, an aid is not yet available on return, a follow-up appointment remains unconfirmed, or nobody knows who is responsible for wound care. This is not necessarily the fault of any one individual. At transition points, many different departments must pass on information and responsibility in good time.
Good preparation makes the transition clear: What was the situation before admission? What is different now? What needs to be done at home from the very first day? Who is responsible for the individual steps? And who can be contacted if information is missing or the patient’s condition deteriorates?
A handover is well prepared when changes are understood, follow-up care is organised and responsibilities for the first few days are clarified.
02
Admission and stay: understanding changes
During a hospital stay, care often changes rapidly. Tests are carried out, medication is adjusted, new assessments are made and discharge is prepared. It is therefore helpful for relatives to clarify at an early stage who is responsible, which questions are important and what changes are on the horizon.
Provide an update on the patient’s current condition on admission
The hospital needs as clear a picture as possible of the patient’s previous care. It is helpful to provide the current medication schedule, known diagnoses and allergies, any existing powers of attorney or advance care directives, as well as details regarding mobility, orientation, communication, assistive devices and support in daily life. In the event of an unplanned admission, this information can be taken from the emergency folder.
It is particularly important to describe the person’s initial condition: What could the person do independently before admission? Where did they need help? What is new or significantly different compared to before? This comparison makes it easier later on to realistically assess the support needed for their return home.
Who is responsible?
In hospital, several professional groups are usually involved: doctors, nursing staff, therapists, social services, discharge management and, where applicable, specialist departments. It is important for relatives to know who the main point of contact is and through which channel information can be reliably passed on.
Helpful questions include, for example:
Which ward is responsible?
Who is the attending doctor?
Are there set times for meetings with relatives?
Who is coordinating the discharge?
Have social services or discharge management already been involved?
Who informs relatives of any important changes?
It may be helpful to designate a main point of contact within the family. This allows information to be passed on in a centralised manner and helps to avoid conflicting updates. The person requiring care should be involved as much as possible. To enable the hospital to inform relatives or pass on details for follow-up care, consent, a power of attorney or some other form of authorisation must be in place.
What questions should relatives ask?
Relatives often know more about daily life at home than the hospital does. Their information can therefore be important for treatment. At the same time, they should ask specific questions so that care can be arranged after discharge.
Important questions might include:
What is the current reason for the treatment?
Which diagnoses have been confirmed or newly made?
Which tests have been carried out or are planned?
Have there been any changes to medication?
Are there any new risks, such as a risk of falling, swallowing difficulties, confusion or wounds?
How mobile is the person at present?
Is physiotherapy, occupational therapy, speech and language therapy or any other form of therapy recommended?
Will a care service be required after discharge?
Are any aids required, for example a rollator, a care bed, a commode chair or a shower stool?
What follow-up appointments are necessary?
When is discharge expected to take place?
It is particularly important to ask about the practical implications. Not just: “What has been diagnosed?”, but also: “What does this mean for life at home?” It is precisely at this point that uncertainties often arise later on.
What changes are there?
During the stay, you should, as far as possible, make a note of what has changed compared to the situation before admission. This applies not only to diagnoses and medication, but also to independence, resilience and the need for support.
Important changes may include:
new or changed medication
medications that have been discontinued
new diagnoses or suspected diagnoses
changes in mobility
an increased need for assistance with personal hygiene, getting dressed or using the toilet
Wounds or necessary dressing changes
changes in diet or fluid intake
Difficulty swallowing
Confusion or delirium
Pain
New aids
Recommended treatments
Necessary follow-up checks after discharge
A simple overview is helpful: What was the situation before the hospital stay? What has changed now? What needs to be organised after discharge? This allows any outstanding issues to be identified early on and clarified specifically with the ward, social services, the care service or the GP’s surgery.
During the hospital stay, it is not the role of relatives to make medical decisions themselves. The key is to gather information, understand any changes and prepare for the return home in good time. This provides reassurance for the person requiring care and takes the pressure off everyone who will be taking on responsibility after discharge.
03
Discharge management: What needs to be clarified before returning home
Discharge from hospital is an important transition. For relatives, this moment often marks the start of a particularly challenging phase: hospital treatment ends, but at home, medication, care, medical aids, appointments and monitoring must continue reliably. It is therefore important to clarify, if possible before discharge, what has changed and what specifically needs to be organised.
The hospital’s discharge management team should identify individual needs for follow-up care at an early stage and prepare for the transition in collaboration with the relevant organisations. Relatives do not have to take on this coordination alone. However, they can provide important information about the situation at home, highlight any outstanding issues and ask who will arrange the next step.
Changes to medication
An up-to-date medication plan is particularly important. Following a hospital stay, medications are often newly prescribed, discontinued or have their dosages altered. Relatives should check whether the following is clearly identifiable: Which medications are new? Which previous medications have been discontinued? Which dosages have been changed? Which medicines are only intended for temporary use? Which on-demand medication is permitted, and at what dosage? Are there any prescriptions or a discharge prescription available? The new medication plan should not be kept alongside an old one at home. Otherwise, mix-ups can easily occur.
New assistive devices
Following an illness or operation, the need for support may change. A rollator, care bed, shower stool, commode chair, positioning cushion or other aid may be required. It is important to clarify at an early stage which aid is recommended, who prescribes it, who supplies it, and whether it will already be available and ready for use at home upon your return.
Prescriptions
As well as medication, other prescriptions may be necessary, for example for home nursing care, dressing materials, wound care, physiotherapy, occupational therapy, speech and language therapy or assistive devices. Relatives should enquire which prescriptions are issued directly by the hospital and which must subsequently be organised through the GP’s surgery.
Care level and care service
If the need for support has increased, it is important to check whether a care level needs to be applied for or whether an existing care level needs to be adjusted. A care service may also be required, for example for personal care, administering medication, insulin, compression stockings or wound care. It is important not to wait until the day of discharge to start looking for these services. The hospital’s social services department or discharge management team can help with the arrangements.
Follow-up appointments
Further check-ups are often necessary after discharge. These include appointments with the GP, specialist consultations, laboratory tests, wound checks, X-ray checks or follow-up appointments at the hospital. Relatives should make as specific a note as possible: Which check-up is necessary? By when should it take place? At which surgery or facility? Who arranges the appointment? What documents need to be brought along? A general recommendation such as ‘a follow-up check-up in the near future’ should be made as specific as possible.
Wound care
If a wound needs dressing, it should be clear before discharge who is responsible for this. Relatives should know whether a care service will be involved, what dressing materials are required, how often the dressing should be changed, and when changes in the wound’s condition require medical consultation. It is also important to provide guidance on warning signs such as increasing redness, swelling, pain, oozing, an unpleasant odour or a fever.
Physiotherapy and occupational therapy
Following a hospital stay, therapy can be important for restoring mobility, strength, independence and confidence in carrying out daily activities. Physiotherapy primarily supports movement, balance, strength and the ability to walk. Occupational therapy can help to practise everyday skills such as getting dressed, washing, eating, grasping objects or using assistive devices safely. Relatives should clarify whether a prescription will be issued, how urgently therapy should begin and what the main objectives are.
A helpful question for relatives
Before discharge, one simple question is particularly helpful:
What needs to be done differently at home from the very first day compared to before the hospital stay?
This question usually highlights the most important points: new medication, new assistive devices, additional care needs, necessary check-ups, therapy, wound care and outstanding tasks. Good preparation for discharge ensures that relatives do not have to wait until they are at home to find out what actually needs to be sorted out.
The first few days at home: checking that care arrangements work in practice
The first few days after discharge will reveal whether the plan you’ve prepared actually works in everyday life at home. Routes, stairs, the bathroom and the support available differ from the situation in hospital. At the same time, new instructions must be followed and any changes in your condition must be closely monitored.
What to look out for?
After discharge, particular attention should be paid to any changes compared with the period before the hospital stay. Important factors include, for example:
Does the person seem more alert, stable and resilient, or rather weaker?
Can they get up, walk and move around the home safely?
Are they managing to eat and drink?
Are they taking their medication correctly?
Are they experiencing any new pain, shortness of breath, dizziness or nausea?
Is there a fever or any other signs of infection?
Does the person seem more confused, restless or unusually tired?
Is a wound or dressing getting worse?
Are there any falls or near-falls?
Are they able to use the toilet, pass urine and have bowel movements?
It is helpful to make a brief daily note. You do not need to document every single action. What matters are any abnormalities, changes and unresolved questions. This makes it easier to recognise whether it is a one-off observation or a trend that needs to be investigated.
When should you contact a doctor?
It is advisable to consult a doctor if the patient’s condition worsens, new symptoms arise or instructions from the hospital are unclear. Particular attention should be paid, for example, to severe or increasing pain, shortness of breath, chest pain, fever, new-onset confusion, marked weakness, repeated vomiting, falls, abnormal blood sugar or blood pressure readings, problems with taking medication, or signs of a wound deteriorating.
Organisational uncertainties should also be clarified at an early stage: is a prescription missing? Is there a contradiction in the medication plan? Has a follow-up check-up been recommended but no appointment arranged? Is it unclear who is responsible for wound care? Such outstanding issues can delay follow-up care and should therefore be specifically reported to the relevant department.
In the event of acute emergencies, such as severe shortness of breath, chest pain, signs of a stroke, impaired consciousness, serious falls or life-threatening hypoglycaemia, the emergency services should be called immediately on 112.
Who is responsible for which tasks?
After discharge, it should be specified as clearly as possible who is responsible for which tasks. Particularly in the first few days, many things often happen at once. If responsibilities remain unclear, tasks can easily be carried out twice or overlooked entirely.
Important tasks may include:
Preparing medication according to the new schedule
Collecting prescriptions and checking stock levels
Arranging follow-up appointments
Organising care services or therapies
Arranging wound care
Procure or adapt assistive devices
Ensure meals, drinks and shopping are taken care of
Documenting readings
Filing doctors’ letters and documents
Informing relatives or neighbours
Organising cover for the main carer
A simple task list is particularly helpful: What is urgent? Who is taking care of it? By when does it need to be done? What has already been completed? This brings greater clarity during what is already a stressful time.
The first few days are not just for recovery. They reveal whether medication, aids, support and the living situation are suitable or need to be adjusted.
05
If information or support is missing
Even with good preparation, information may be missing or practical questions may remain unanswered on the day of discharge. It is then crucial to identify the uncertainty precisely and refer it back to the relevant department, rather than continuing to operate on assumptions at home.
The discharge summary arrives late
The discharge letter contains important information on diagnoses, treatment, medication and recommended follow-up appointments. However, sometimes only a provisional letter is available at the time of discharge, or documents are sent on later. Relatives should therefore clarify which information is available immediately, whether a final discharge letter will follow, and to whom it will be sent. It is also important that the GP’s surgery receives all relevant documents promptly.
Medication has been changed
Following a hospital stay, the medication plan is often different from before. Medications may be newly prescribed, discontinued or have their dosage adjusted. It becomes particularly risky if old packs, old medication schedules or pre-prepared pill boxes are still present at home. Therefore, immediately after discharge, it should be checked which schedule is currently in force and which old instructions must no longer be followed.
Assistive devices are missing
Sometimes it only becomes clear once at home that an aid is urgently needed: a rollator, a care bed, a commode chair, a shower stool, grab rails, incontinence products or dressing materials. If such aids are missing, care may become unreliable or relatives may be placed under unnecessary strain. It is therefore important to clarify, if possible before discharge, which aids are required, who prescribes them, who supplies them and when they will be available.
Unclear prescriptions
It is not always immediately clear which services need to be arranged following discharge. Home nursing care, wound care, physiotherapy, occupational therapy, speech and language therapy or certain dressings often require a prescription. Relatives should check whether this has already been issued or whether the GP’s surgery still needs to arrange it.
‘Check-up with the GP’ is too vague
Discharge documents often state that a check-up with the GP is required. This information is often insufficient for day-to-day practicalities. More importantly: when exactly should the check-up take place? Within two days, within a week, or only if symptoms arise? What needs to be checked: blood test results, blood pressure, wounds, medication, general condition? Relatives should ask for as much specific detail as possible.
Responsibilities are unclear
After discharge, many tasks come together: organising medication, arranging appointments, informing the care service, obtaining aids, forwarding documents, monitoring changes. If it is not clear who is responsible for what, important steps can easily be overlooked. A simple to-do list for the first few days can help make the transition smoother.
The actual need for support is underestimated
Sometimes the person in need of care appears more stable in hospital than they actually are at home. The layout is different, the bathroom is smaller, stairs need to be negotiated, and relatives are not available round the clock. It is therefore important to monitor closely during the first few days whether care at home is really working or whether additional support is needed.
From an organisational point of view, a discharge is only complete once it is clear at home what needs to be done, what is still missing and who will take care of the outstanding tasks.
