Why discharge planning matters
The first two weeks after a hospital discharge are among the most dangerous for elderly patients. Readmission rates are highest in this window, often because of medication confusion, falls, or care gaps at home.
Good discharge planning starts while your loved one is still in hospital — not on the day they leave.
Before discharge: questions to ask the ward team
- What is the diagnosis, and what does recovery look like?
- Have any medications changed? (New ones added, old ones stopped, dosages adjusted?)
- Are there any dietary restrictions or activity limitations?
- What follow-up appointments are needed, and who will arrange them?
- Are there any red-flag symptoms that should prompt an immediate return to hospital?
- Has an occupational therapy assessment been done for the home?
- Is a referral to community or district nursing needed?
Write everything down. Discharge conversations often happen quickly, and it's easy to forget details once you're home.
Preparing the home
Depending on your loved one's condition, the home may need adjustments:
- Falls prevention: remove trip hazards (rugs, trailing cables), ensure good lighting on stairs and in the bathroom, consider grab rails
- Bedroom: if stairs are difficult, set up a temporary bedroom downstairs
- Bathroom: a shower stool, raised toilet seat, or bath board may be needed
- Medication: have the new medication regime ready — pre-sorted in a pill organiser or blister pack
- Food: stock the fridge and freezer with easy, nutritious meals
The first 48 hours at home
The first two days are critical. Plan for someone to be with your loved one as much as possible:
- Supervise the first few medication doses to ensure the new regime is understood
- Watch for signs of confusion, pain, or deterioration
- Ensure they're eating and drinking enough
- Help them move around safely — they may be weaker than expected after even a short hospital stay
Coordinate with the care circle
Don't try to manage the post-discharge period alone. Share the discharge summary with your care circle, set up a visiting rota for the first week, and use care requests to divide tasks like pharmacy runs, meal preparation, and appointment transport.
If community nursing or physiotherapy visits are arranged, make sure everyone in the circle knows the schedule so someone is always there to let them in.
When to seek help
Contact the GP or call 111 if your loved one experiences:
- Increasing confusion or drowsiness
- Fever, new pain, or wound redness
- Difficulty breathing
- Unable to eat or drink
- A fall or near-fall
Don't wait and hope things improve. Early intervention after discharge can prevent a return to hospital.