August 18, 2021 | Net Health

3 Minute Read

Facilitating Patient Transitions to At-Home Care

Care expectations are evolving, shifting away from in-facility models to more familiar frameworks that allow patients to receive health services and support at home. Pandemic pressures have accelerated this change. Given that severe outcomes are occurring with greater frequency in non-home care settings, many older Americans now prefer to stay at home as long as possible.There are also economic benefits tied to this shift: A recent research study found that, on average, home care was associated with $4,514 in savings in the 60 days after hospitalization.2

For both patients and hospice and home health providers, however, delivering the best experience for patients requires effective transitions that address the unique challenges of moving from more intensive health services to adaptive at-home care. Here are three ways to help facilitate this transition.

1) Recognize the Challenges

As noted by the Palliative Care Network of Wisconsin, the biggest challenge in making the move to home-based care is complexity: “The transition from hospital to home for the patient about to be enrolled in home hospice care is complex.  Miscommunication between hospital staff and hospice care providers regarding goals of care and medications occurs commonly and only heightens existing stress and fear among patients and their caregivers.”3

To facilitate patient transitions, it’s critical to both recognize and prepare for these challenges by creating a coordinated dispatch plan that includes the transfer of all relevant digital data, in-depth review of any symptoms or ongoing conditions with both facility care and home health/hospice staff, and assessments of any potential health challenges in the near future caused or exacerbated by the move. 

2) Organize the Environment

Environmental organization is also critical. Here’s why: As noted by a study from the Journal of Hospice and Palliative Nursing, while healthcare professionals typically view the transition to home care as an “event,” patients and their families describe it as a “process.” This speaks to their lived experience. For providers, transition is a point in time that repeats, while for families and patients the move to at-home care involves both initial setup and ongoing experiences.

To help facilitate this process, organization is key. This starts with tools such as home health and hospice EHR software that allow the streamlined collection and access of critical patient data for staff, and is bolstered by the creation of physical spaces in the home that strike a balance between necessary medical equipment — such as hospital beds, IV stands or oxygen tanks — and the more familiar comforts of home. 

3) Optimize the Care

One of the biggest benefits of at-home care is the connection patients can forge with healthcare workers. As noted by a recent National Center for Biotechnology Information (NCBI) paper, more than half of nursing care residents said they felt lonely, and recent pandemic restrictions only increased these feelings of isolation.5

In-home care offers the potential for staff to connect with patients — but only if current care conditions are optimized to reduce the amount of time caregivers need to spend completing reports and ensuring compliance obligations are met. Home health and hospice software systems can help bridge the gap by providing a centralized, compliant data entry portal that lets caregivers get back to what they do best: supporting patients.


World Economic Forum, “Safer, Cheaper and Healthier: It’s Time to Look Again at Home Care for Older People,” October 13, 2020.
Leonard Davis Institute of Health Economics, “Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility,” March 11, 2019.
3 Palliative Care Network of Wisconsin, “Hospice Referral: Moving from Hospital to Home,” 2020.
4 Journal of Hospice and Palliative Nursing, “The Experience of Transition From Hospital to Home Hospice,” November 2011.
5 National Center for Biotechnology Information (NCBI), “Loneliness and Isolation in Long-Term Care and the COVID-19 Pandemic,” May 8, 2020.

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