Post-Hospital Home Care
The first 30 days after a hospital stay are the highest-risk period for re-hospitalization. Coordinated home care during this window protects recovery and gives families peace of mind.
Why the First 30 Days Matter
Hospital readmissions in the first 30 days after discharge are common — particularly among older adults recovering from cardiac events, joint surgery, pneumonia, or COPD exacerbations. The drivers are usually preventable: medication errors, missed follow-up appointments, wound complications, and falls. A coordinated home health plan addresses each of these directly.
What Our Post-Hospital Care Includes
- Skilled nursing visits for wound care, medication reconciliation, IV therapy, and ongoing assessment of vital signs and symptoms.
- Physical and occupational therapy to rebuild strength, mobility, and independence in daily activities.
- Personal care assistance with bathing, dressing, and transfers during the period when patients are most at risk for falls.
- Medication management to make sure new prescriptions are taken correctly and to flag interactions with existing medications.
- Coordination with your physician — we update the doctor on progress and flag concerns early.
- Education for family caregivers on what to watch for and how to help.
Common Conditions We Support
- Joint replacement (hip, knee, shoulder) recovery
- Cardiac surgery and heart failure
- Stroke recovery
- Pneumonia and respiratory illness
- COPD exacerbation
- Abdominal and spine surgery
- Falls and fracture recovery
- Sepsis recovery
How Discharge Planning Works
- Hospital discharge planner contacts us 24 to 48 hours before discharge when possible.
- We review the discharge orders and confirm what care is needed.
- Nursing supervisor builds the plan of care and coordinates with the physician.
- Care begins at home, often the same day as discharge.
- Daily handoffs and weekly reviews keep the plan on track.
If your loved one is being discharged soon, tell the discharge planner you want DeGuardian Health, or call us directly at 469-688-3631.
Frequently Asked Questions
How quickly can DeGuardian start care after hospital discharge?
For qualifying patients, we can begin care the day of discharge. The hospital discharge planner should contact us 24 to 48 hours in advance whenever possible so we can confirm orders and arrange staffing.
Does Medicare cover home health after a hospital stay?
Yes, in most cases. If a physician certifies that you are homebound and need intermittent skilled care, Medicare typically covers home health services including skilled nursing, physical therapy, and occupational therapy.
What kinds of conditions does post-hospital home care help with?
Common situations include recovery after joint replacement, cardiac surgery, stroke, pneumonia, COPD exacerbation, congestive heart failure, and major abdominal surgery. Home care reduces the risk of re-hospitalization and supports a smoother recovery.
Can I get home health if I was at the hospital but not admitted as an inpatient?
Medicare home health eligibility is not tied to having had an inpatient hospital stay. As long as a physician certifies need and homebound status, you can qualify regardless of how the recent hospital visit was classified.