Coming home from the hospital: the first two weeks are where things go wrong

Discharge day feels like the end of something. Clinically it is the start of the riskiest stretch. Most avoidable readmissions trace back to something small that got missed in the first two weeks at home.

What actually goes wrong

Not dramatic things. Ordinary ones.

• The medication list changed in the hospital and nobody compared it to the one at home. Two pills now do the same job, or a familiar one silently disappeared.
• A prescription was sent to a pharmacy that does not stock it, so it was never filled.
• The follow-up appointment was in a week or two and never got booked.
• There is no ride to the appointment that did get booked.
• The family was told which warning signs to watch for while standing in a hallway, and nobody wrote it down.
• Home equipment or home health was ordered and never actually showed up.

Any one of these on its own is survivable. Two or three together is how someone ends up back in the emergency room in eleven days.

The checklist a navigator works through

At Life Medical, a navigator calls within a day or two of discharge. Not a week. The call works through the same list every time:

1. Read the discharge paperwork. All of it, including the parts written for clinicians.
2. Reconcile the medications. New list against old list, line by line. Anything that looks duplicated or dropped goes straight to the practitioner.
3. Confirm every prescription was actually filled. Call the pharmacy, do not assume.
4. Book the follow-up visit. With a real date, not an intention.
5. Arrange the ride. Medical transportation gets booked at the same time as the appointment, not the day before.
6. Confirm home health and equipment arrived, and chase them if they did not.
7. Brief the family in writing: which warning signs matter, who to call, and in what order.

Why the timing is the whole point

A call on day two catches a missing prescription while it still matters. The same call on day ten catches it after a week without the medication.

This is also why a discharge is one of the best moments to start navigation. If your Life Medical practitioner has established the diagnosis and plan, navigation can begin right away, and the first month''s work is exactly the list above.

If you are in a skilled nursing facility

A covered skilled nursing stay pauses navigation, because that stay is temporary. Call us anyway. We can be ready for the day you come home, which is the day the risk starts.

Emergencies

If something is acutely wrong, call 911 first. A navigator is not an emergency service. What a navigator prevents is the slow version, where nothing looks urgent until it suddenly is.

Get it set up before the next discharge

Call 973-607-4911. If someone in your family has been in the hospital more than once this year, this is the call to make.

Where this comes from

• AHRQ Re-Engineered Discharge (RED) toolkit — the evidence on what goes wrong after discharge.
• Medicare: your rights when leaving a hospital — discharge planning and appeals.
• Eldercare Locator — home help, meals and transport after a stay.

Related reading on this site

• What a navigator actually does
• Who qualifies
• Does Medicare cover a care navigator?