I recently received a letter from a reader concerned about a problem some of her friends are facing. Either they—or their spouse—have been released from the hospital but remain weak and in need of care. These are couples in their 80s or 90s, and she wonders if any type of medical support is available after hospital discharge.

Let’s begin with the discharge process. Before a patient leaves the hospital, the medical team—including social workers and discharge planners—assesses the patient’s condition, care needs, home environment, and available support. The goal is to determine whether it’s safe for the patient to return home.

At this point, it’s crucial for the spouse to share any concerns about their ability to provide care. This may include physical limitations, their own health issues, anxiety about managing medical routines, the lack of nearby family or friends, or an unsafe home setup—such as no ramps, grab bars, or a first-floor bedroom and bathroom.

Being open and honest helps the team evaluate whether coming home immediately is the best option.

If it’s determined that the spouse cannot safely care for their loved one, the hospital will look for alternatives. These may include:

• Inpatient rehabilitation facilities (e.g., Los Robles East Campus Acute Rehab) for patients needing intensive therapy
• Skilled nursing facilities for short-term medical and rehab care

If returning home is deemed safe but requires additional support, home health services may be ordered. These services provide medical and non-medical care in the home, including nursing care, physical, occupational, or speech therapy, social work, and help with daily tasks like bathing or managing medications. Home health is usually coordinated by an agency and may be covered by insurance, including Medicare.

The medical team will discuss these options and include you in the decision-making process. If a facility stay is recommended, your choices may depend on care requirements, insurance coverage, and bed availability.

If home health care is ordered, the hospital will forward the physician’s instructions to a partner agency—but if you have a preferred agency, speak up during discharge planning.

The discharge team can also help clarify what’s covered by Medicare, Medicaid, or private insurance, and what costs you may need to cover yourself. If no safe option is available immediately, the hospital may delay discharge until a plan is in place.

If everyone agrees that the patient can safely return home without home health care, there are still resources available:

• Private in-home care (non-medical) helps with daily tasks like bathing and grooming. Most services require a 4-hour minimum and cost $40/hour or more.
• Meals on Wheels offers home-delivered meals. Learn more through Senior Concerns.
• Shop Ahoy delivers groceries from Vons in select areas: shopahoy.net
• Caregivers: Volunteers Assisting the Elderly can provide companionship while you attend appointments: vccaregivers.org
• Faith-based organizations often have volunteer support as well.

By understanding your options and speaking up during the discharge process, you can help ensure a safer, more supported transition from hospital to home.