Home Care After a Hospital Discharge in New Jersey: A Family Checklist

To set up home care after a hospital stay, start before discharge day: ask the hospital's case manager for the discharge plan, the medication list and a home health referral if skilled care is needed. Then line up who covers each job at home for the first two weeks, because that is when most problems start.

This checklist is what our nurses walk families through in Burlington, Camden, Gloucester, Mercer and Atlantic counties.

Before discharge: questions to ask the hospital. • What is the diagnosis, in plain words, and what should recovery look like week by week? • Which medications are new, which changed, and which should stop? Ask for the list in writing. • Does the patient need skilled nursing, physical therapy, occupational therapy or speech therapy at home? If yes, ask for the home health referral and the agency's name. • What equipment is needed (walker, shower chair, raised toilet seat, hospital bed), and who orders it? • When is the first follow-up appointment, and with whom? • Which symptoms mean "call the doctor" and which mean "call 911"?

The first 48 hours at home. Fill every prescription before the patient gets home, or on the way. Compare the new medication list with the pill bottles already in the house and set aside anything the hospital stopped. Write the follow-up appointments on one calendar the whole family can see.

Set up one floor. For the first week, put everything the patient needs on one level: a bed, a clear path to the bathroom, a night light, water, snacks and a charged phone. Move rugs and cords out of walking paths. A shower chair and a grab bar cost little and prevent the most common fall at home.

Give each job an owner. Families who do well split the work clearly. One person owns medications. One owns appointments and transport. One owns nights and weekends. When everyone helps with everything, things get missed.

Where home care fits. • Skilled nursing checks vital signs, wounds and medications, and teaches the family what to watch for. • Physical and occupational therapy at home rebuild strength and make daily tasks safer, using the patient's own stairs, bathroom and kitchen. • A home health aide helps with bathing, dressing and moving safely. • A companion helps with meals, errands and company, so the patient is not alone for long stretches.

If the patient qualifies under Medicare's home health rules (homebound, with a skilled need and a doctor's order), the skilled visits are usually covered. Extra aide or companion hours are often private pay. Ask any agency to explain the difference before care starts.

Warning signs in the first two weeks. Call the doctor or the home care nurse the same day for new confusion, fever, a wound that is red or draining, pain that keeps getting worse, a fall, swelling in one leg, or not eating or drinking. Call 911 for chest pain, trouble breathing, or sudden face drooping, arm weakness or slurred speech.

If you are a discharge planner or case manager. You can refer a patient to Neuron Health Systems through the referral form on our website, and our intake team will call the family.

Getting started. Call (856) 389-5089, Monday to Friday, 8 AM to 5 PM, or book a free consultation online. If you call before discharge, we can often plan the first visit for the week the patient comes home.