Hospital to Home: A Family Caregiver's Discharge Planning Checklist
The days immediately after hospital discharge are the highest-risk period for readmission. Here is exactly what to do before, during, and after discharge.
Contents
Hospital discharges happen fast, often faster than families feel ready for. A patient who seemed unwell yesterday is told they are going home tomorrow, and suddenly there is an enormous amount to organise with very little time to do it. Families who have a plan navigate this transition safely. Families who do not are the ones who end up back in A&E within two weeks.
📋 In this guide
- What to do before the discharge day
- Questions to ask before leaving the hospital
- What to check and confirm on discharge day
- The first 48 hours at home: what to watch for
- Setting up ongoing care coordination after discharge
Before Discharge Day
Get involved in the planning early
Do not wait for the hospital to tell you the discharge plan. Ask on day two or three of the admission who the discharge coordinator is and what the expected timeline looks like. The earlier you are involved, the more influence you have over the arrangements.
Ask specifically: Will there be a need for rehabilitation services? Physiotherapy? Occupational therapy assessment of the home? District nursing visits? Equipment like a commode, raised toilet seat, or hospital bed? These take time to arrange, and discharge is delayed (or worse, rushed) when they are not requested early.
💡 Request a home visit assessment before discharge
If there are any concerns about how the patient will manage at home, request an occupational therapy home visit before discharge. A therapist can identify modifications needed and recommend equipment. This is far easier to arrange before discharge than after.
Prepare the home
Walk through the home and remove trip hazards: loose rugs, cables across walkways, obstacles in corridors, anything that creates a fall risk for someone who may be moving less steadily than usual. Falls in the first weeks after discharge are extremely common and frequently cause readmission.
If stairs will be a problem, set up a temporary living and sleeping arrangement on the ground floor. If the bathroom is upstairs, confirm whether a commode downstairs is needed.
Check that the medication situation is organised. Know which medications were being taken before admission, which have changed, and have a plan for picking up or receiving any new prescriptions immediately.
Questions to Ask Before Leaving the Hospital
Before signing discharge paperwork, get clear answers to these questions. If possible, have someone with you to take notes, because there is always more information than one person can retain.
Medication questions:
- "Can you go through the complete medication list with me now, including anything that has changed?"
- "What should I watch for as side effects of any new medications?"
- "Which medications need monitoring (blood tests, blood pressure checks)?"
Follow-up questions:
- "Has a follow-up appointment with the GP been booked, or do I need to book it?"
- "Is there a follow-up with the consultant or specialist, and when?"
- "Who do I call if I am concerned about something in the first week?"
Condition and care questions:
- "What are the warning signs that something is wrong and I should seek help?"
- "Are there any restrictions on activity, diet, or lifting?"
- "Is there a wound or dressing that needs changing? When, and who should do it?"
Equipment and services:
- "Has equipment (frame, commode, bed rails) been ordered and will it arrive today?"
- "Have district nursing visits been arranged, and when is the first one?"
⚠️ Get everything in writing
Verbal discharge instructions are routinely forgotten or misremembered. Ask for a written discharge summary, a printed medication list, and written follow-up instructions. If these are not offered, ask for them. You are entitled to them.
→ Upload discharge documents to Care Maple for the whole care team to access
Discharge Day: What to Confirm Before You Leave
On the day of discharge, before leaving the hospital, confirm:
- The complete medication list is in hand (written, not just verbal)
- All prescriptions are with you or being sent to a specific pharmacy
- Any new medical equipment has been delivered or is confirmed for delivery
- The GP follow-up appointment is booked (date and time confirmed, not "you need to call")
- District nursing or home care visits are arranged with specific start times
- You have the name and number of a clinical contact to call if concerns arise in the first week
Missed appointments in the weeks after discharge are a major contributor to readmission. Set reminders for every follow-up appointment before you leave the building.
The First 48 Hours at Home
The first two days after discharge carry the highest risk. Your loved one may feel significantly worse at home than they did in hospital (the transition itself is tiring) or they may overestimate their recovery and try to do too much. Both are dangerous.
What to monitor in the first 48 hours:
- Temperature (low-grade fever can indicate infection)
- Wound appearance if there is a surgical site (redness, swelling, discharge)
- Medication taken on time and without adverse reaction
- Fluid and food intake
- Mobility and balance when moving around the home
- Pain level
- Confusion or changes in cognition (can indicate infection, dehydration, or medication reaction)
Write what you observe. A care journal kept from the first day home is invaluable if something goes wrong and you need to explain to a GP or A&E exactly what happened and when. Proof of care documentation begins on day one.
Setting Up Ongoing Care After Discharge
Hospital discharge often marks the beginning of a sustained period of increased care need. Use the transition as an opportunity to establish the care structures that will be needed going forward.
Set up a shared care record so that everyone involved, whether family members, a district nurse, a home care aide, or a neighbour checking in, can log what they did and what they observed. Coordinating care across a family is far easier when everyone writes to the same record.
Add all follow-up appointments to a shared calendar so nothing gets missed. Record new medications and any instructions from the hospital. Assign specific people to specific tasks so there are no gaps and no duplication.
→ Set up your post-discharge care circle in Care Maple to keep the whole team coordinated
When to Call for Help
In the first two weeks after discharge, contact the GP or the discharge nurse hotline (if one was provided) for:
- Temperature above 38°C
- Signs of wound infection (redness spreading, pus, increasing pain)
- Severe or new pain not explained by the condition
- Difficulty breathing
- Significant change in mental state (sudden confusion, severe drowsiness)
- A fall
- Inability to keep medications or fluids down
- Any symptom the discharge team specifically told you to watch for
When in doubt, call. Post-discharge care teams expect and welcome calls in the first fortnight. The threshold for seeking advice should be lower, not higher, than usual.
💡 Readmissions are often preventable
A significant proportion of hospital readmissions within thirty days of discharge are directly linked to inadequate follow-up, medication errors, or failure to act on early warning signs. The family caregiver, equipped with good information and a clear monitoring plan, is the most effective preventive intervention available.
The weeks after a hospital discharge are critical. Use Care Maple to coordinate your post-discharge care team and make sure nothing falls through the cracks when your loved one needs it most.
Frequently Asked Questions
What is discharge planning and why does it matter?
Discharge planning is the process of preparing a patient and their home for a safe transition out of hospital. It matters because the days immediately following discharge are statistically the highest-risk period for complications, falls, and readmission. Poor discharge planning is one of the most preventable causes of avoidable hospital readmissions.
Who is responsible for hospital discharge planning?
The hospital typically has a discharge coordinator or social worker who manages the process. However, families should not assume this is fully taken care of. Advocate actively: ask specific questions, request written summaries, and ensure follow-up appointments are actually booked before leaving the hospital, not left as a task for after discharge.
What medications changes should I know about at discharge?
Request a complete, updated medication list in writing at discharge. Ask the pharmacist or nurse to explain any new medications, any medications that were stopped, and any dose changes. Medication errors at transition are extremely common and frequently cause readmissions. Do not assume the discharge summary matches what was actually administered.
When should I call the GP after a hospital discharge?
Book a follow-up appointment with the GP within five to seven days of discharge, or sooner if there are new medications to review or any clinical concerns. Many complications and readmissions in the first two weeks post-discharge could be caught and addressed at a timely GP visit.
What home modifications should I make before discharge?
Common adjustments include: removing trip hazards (rugs, cables, clutter in walkways), installing grab rails near the toilet and shower, ensuring the bed is at a safe height for getting in and out, preparing meals in advance, setting up a comfortable recovery area on the ground floor if stairs are difficult, and confirming that medications can be collected or delivered.
Care Maple Team
We help families coordinate care for elderly and dependent relatives — with the tools, documentation, and peace of mind that comes from a well-organised care system. Every article is written from real caregiving experience.
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