Transition to Home

The attending physician, with input from the team of caregivers, will determine when a patient is ready to leave the hospital. Sometimes a patient will need continued assistance at home or time at a rehabilitation facility. Case managers work with patients and their family members to create a transition plan and coordinate any necessary community resources.
Helping a patient transition to home at Boston area hospital

Planning for Transition

Case managers meet with patients on the day after admission to discuss anticipated follow-up care. Working with the patient and the health care team, the case manager develops a plan for transition to home or another level of care. This plan is re-evaluated daily and kept up to date on the white board in the hospital room. The day before discharge, patients meet with their case managers and family members to establish a discharge time and plan. 

Discharge Instructions

The attending physician and nurse give patients instructions about post hospital care, including diet, medications, activities, follow-up care and equipment needs. Patients will need to make arrangements with family or friends ahead of time to arrange for transportation home and assistance once at home. Patients who go from the hospital to a rehabilitation facility will have transportation arranged for them by the case manager.

Rehabilitation Hospitals and Home Care

Spaulding Hospital North Shore

Spaulding Hospital North Shore is a member of Partners Health Care System. Spaulding Hospital North Shore is designed for patients who need short-term rehabilitation and specialized nursing care before going home. Spaulding North coordinates with North Shore Medical Center closely to provide a smooth transition.

Partners Home Care

Partners Home Care is a full service, Medicare-certified home care agency that supplies nurses/nurse aides, medical social workers, therapists and adult sitter services. Partners Home Care also provides hospice services for those coping with a life-limited illness, and Lifeline, an emergency response service.