Coming home from the hospital: what the first 72 hours should look like

Going home is the goal of every hospital stay, and it is also the moment things are most likely to slip. There are new medications, a body that is weaker than it was a week ago, and a discharge packet nobody has time to read. As a nurse, I can tell you the first three days at home set the tone for the whole recovery. Here is what they should look like.

Why the first few days matter most

In the hospital, someone checks on you around the clock. At home, that safety net disappears overnight. Most problems after discharge are not dramatic. They are a missed dose, a new prescription that doubles up with one already in the cabinet, a fall on the way to the bathroom at 2 a.m., or a symptom nobody realized was worth a phone call.

Those are exactly the problems a home health nurse or therapist is trained to catch early. That is why the first visit should happen quickly, ideally within a day or two of getting home.

Before you leave the hospital

If you can, ask the case manager or discharge planner for a home health referral before discharge day. You can name the agency you want. Medicare requires hospitals to respect your choice of home health agency, as long as the agency serves your area and works with your plan.

Also ask for an up to date medication list that shows what is new, what changed, and what to stop, along with the name of the doctor who will follow you after discharge.

What happens at the first home visit

The first visit is longer than the rest, usually an hour or more. Your nurse or therapist will:

• Go through every medication in the house, including the ones from before the hospital, and sort out duplicates, changes, and anything that should stop.
• Check vital signs, look at any incision or wound, and walk through the home for fall risks like loose rugs, poor lighting, and a hard to reach bathroom.

From there, we build a plan of care with your doctor: how often we visit, which disciplines you need, and what goals we are working toward. A family member is welcome at that first visit, and usually helpful.

Medications are the big one

If I could ask families to do one thing, it would be this: gather every pill bottle in the house into one bag before our first visit. That includes vitamins, over the counter medicines, and anything prescribed before the hospital stay. Medication mix ups are one of the most common reasons people end up back in the hospital, and they are among the easiest to prevent.

Call the doctor or your home health nurse if you notice

• A new fever or chills, or redness, warmth, or drainage around an incision.
• Shortness of breath that is new or getting worse, or new swelling in the legs.
• Confusion, unusual sleepiness, or a sudden change in how someone is acting.
• A fall, even one that seems minor. For chest pain, severe trouble breathing, or signs of a stroke, call 911 first.

How Medicare covers it

For patients who qualify, Medicare pays 100% of covered home health visits, with no deductible or copay. The Medicare Advantage plans we accept, including HealthSpring, also cover home health visits at 100%. We also accept VA Community Care and private pay. Our guide to who qualifies for Medicare home health explains the four rules in plain English, and we verify benefits before the first visit so nobody is surprised.

After the first week

Visits usually settle into a rhythm of a few times a week, tapering as you get stronger. Nursing, physical therapy, and occupational therapy can all be part of the plan. The goal is always the same: get you safe, steady, and independent at home, then step back.

The fastest way to get started

Call 844-808-9096 before or right after discharge and tell us what happened. We will contact the hospital or physician for the order and schedule the first visit. Case managers and physicians can fax orders and a face sheet to 904-638-8752.

This article is general information, not medical advice. If you are worried about a symptom, call your doctor. In an emergency, call 911.