Pathfinders Programs

Hospital to Home Transition

To help you with the challenges associated with bringing your loved one home from the hospital

Most people look forward to the day their loved one is discharged from the hospital. But as that day grows closer, sometimes excitement is tinged with anxiety. Are you really ready? Do you understand the discharge instructions? Do you have the right people coming in to help? Have you scheduled the correct follow up appointments?

The good news is that the more you know about the hospital to home transition, the more prepared you’ll be so you can avoid many of the pitfalls that can so often occur.

Pathfinders is here to work with you each step of the way. We’ll help you get ready for discharge and ensure that your loved one is well cared for once they return home. We’ll also be there, when you can’t, to make sure that once your loved one is home, they’ll stay there.

While most people think of a medical discharge as something that occurs at the end of a hospital stay, the transition actually happens in three stages.

The first occurs as soon as your loved one is admitted to the hospital. Pathfinders will meet with you, at the bedside, to help you communicate effectively with the medical team, to ensure that insurance and legal forms are up to date, to complete your discharge checklist, and to ensure that your loved one is being well cared for.
Stage two happens at the time of discharge, when your medical team prepares your loved one to come home. Pathfinders will accompany you through the discharge process to ensure good communication between you and the discharge team. We’ll be on-site to make sure you understand and are comfortable with instructions for follow-up appointments, medications, equipment, and nutrition.
The last stage occurs at home. Pathfinders will be there to oversee proper use of medications, adherence to nutritional guidelines, and compliance with medical appointments and treatment protocols. We’ll communicate with you, if you’re not on the premises, to update you on progress and concerns.

Pathfinders is always on call to identify appropriate resources for support and education, should the need arise. Furthermore, we’re there to mediate should communication issues arise between family members or the medical team, and we’re also available to assist you should a medical crisis occur.