We take care of family

Hospital to Home

The Importance of a Successful Discharge and Transition Home

Are you preparing for discharge from the hospital or rehab facility to your home? Do you know a loved one that needs care and are struggling to provide them the adequate care? If you’re a family caregiver it can be overwhelming and confusing to try to balance caring for your loved one at the same time as taking care of preexisting responsibilities like a job or family. As you attempt to match available resources with the needs of your loved one, knowing they are coming home from the hospital soon, it can be daunting to find the right care to make sure they will remain safely in their home.


Did You Know?

20% of all Medicare patients are readmitted to hospitals within 30 days

33% are readmitted within 90 days

*According to a 2009 national study in the New England Journal of Medicine


There are several underlying contributors to the staggering number of patients facing a hospital readmission and most, if not all, of the contributing factors can be addressed by extending the care you or your loved one needs from the hospital to the home.


Fedelta Home Care has developed a comprehensive program to help our clients ensure a safe transition home and prevent readmissions to hospitals when possible.  Your dedicated care manager will participate in the hospital or acute care setting discharge process to assess needs, create a detailed care plan, prepare a start of care document and monitor progress.


Core Programs Elements:


The following model has proven successful when a multidisciplinary approach is taken.  However, we recognize that each client has unique needs and may benefit from some or a part of the following program elements:

Home Care - Professional Caregiver

Care Management - Care Manager

  • Transportation home
  • Review discharge plans
  • Pick-up medications from pharmacy
  • New medication reminders
  • Safety observation and change in condition
  • Hydration, Meal preparation (special diet)
  • Stand-by walking assistance
  • Bathing, dressing, grooming assistance
  • Range of motion exercises
  • Laundry and light housekeeping
  • Mail retrieval
  • Communication with family and care manager
  • 4-hour to 24 hour care services
  • Physician follow-up
  • Comprehensive client assessment and participation in hospital discharge planning
  • Development and implementation of a client centered care plan and goal setting
  • Assistance with medication and behavioral management
  • Scheduled care calls (optional)
  • Scheduled home visits (optional)
  • Ongoing communication and collaboration with family members and other care providers
  • Caregiver supervision and support
  • Home Safety Assessment & Modification
  • Senior Housing Options (if applicable)

Every day, we hear from happy clients who tell us they're glad they trusted Fedelta with this important decision. We invite you to see what they have to say.

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