Avoid a Return Trip to the Hospital

Patients who may be at risk for hospital admission often include:

  1. Patients who may potentially experience problems with medications, such as individuals who must take multiple medications or are on high-risk medications (e.g., blood thinners, insulin, narcotics, etc.).
  2. Patients who screen positive for depression or who have a history of depression.
  3. Patients with a principal diagnosis or reason for hospitalization related to cancer, stroke, diabetic complications, COPD, or heart failure.
  4. Patients with frailty or other physical limitations that impair or limit their ability to significantly participate in their own care (e.g. perform activities of daily living, medication administration, and participation in post-hospital care).
  5. Patients with limited knowledge of or familiarity with basic health information and services understand basic health information and services ).
  6. Patients with poor social support, such as the absence of a reliable caregiver to assist with the discharge process and to assist with care after the patient is discharged.
  7. Patients who experienced an unplanned hospitalization in the six months prior to the current hospitalization.
  8. Patients who are currently undergoing palliative care.

Tip: Start a notebook


  • A list of your medicines
  • Names of your doctors
  • Laboratory results
  • Instructions
  • A copy of your medical records
  • Questions you need to ask
  • Take your notebook with you to each doctor’s visit.

Tip: Repeat instructions about your medications

Before You Leave the Hospital

You will be given instructions. A nurse or other staff member will go over your instructions. Ask a family member or friend to help ask questions and write down information. It’s important to follow all of the instructions.

Find out about your condition

  • What treatment or procedures did you receive in the hospital and why? Do you have any new medical conditions?
  • Should you limit activities?
  • Should you avoid any foods, caffeine, alcohol, tobacco or other drugs? Do you need any referrals? Referrals may be needed for:
  • New doctors or other health care providers
  • Tests or therapy
  • Home care services
  • Medical equipment, like a walker or oxygen

Ask about your medicines

  • Are you taking any new medicines? If you are, find out:
    • Why are you taking new medicines?
    • What are the side effects?
    • How long do you need to take it?
    • What should you do if you feel it isn’t working?
    • Can you take it with your regular medicines, vitamins or supplements?
  • What medicines will you need to take at home? Ask about both your regular and new medicines. Were any of your regular medicines changed to generics or other similar medicines? Make sure you don’t take a double dose after you leave the hospital.
  • Do any of your prescriptions need to be filled?
    • Can you pick up your prescriptions in the hospital before you leave?
    • Can a family member or friend take you to the drug store? Or can they pick up your prescriptions for you?

Follow through on your follow-up care

  • Will you need follow-up tests or treatment?
  • Do you need a follow-up appointment with your surgeon or other doctors?
  • When do you need to see your regular doctor? Be sure to tell your doctor about your hospital visit. Ask your nurse or another staff member to make your follow-up appointments. Make sure the appointments are at times that are convenient for you.
  • Have you talked to a social worker or case manager about finding services in your community?

Get information about getting help if you need it

  • What is the number to call if you have a question? Who do you call after hours if you have a problem?
  • What symptoms should cause you to call your doctor immediately?
  • What symptoms should cause you to go to an urgent care center or to the emergency room? What should you do if you have pain?

After You Leave the Hospital

Depending on your condition, the type of care you need may include the following:

Regular doctor visit

Your regular doctor can answer questions about your:

  • Condition
  • Treatment
  • Follow-up care
  • Medicines

(examples: Check wounds for infection, Remove stitches, Order blood or urine tests, etc.)


Most therapy is provided at therapy centers. This is called outpatient care. Some patients need around-the-clock care in a rehabilitation hospital. This is called inpatient care.

  • Examples: Physical, occupational or speech therapy

Home care

A variety of care or services are provided to patients in their home, such as:

  • Nursing care
  • Delivery of oxygen tanks of medical supplies
  • Help with personal care, like bathing
  • Help finding community resources

Community services

Most communities have services to help patients stay in their home. A social worker or case manager can help find resources in your community.


  • Meals on Wheels
  • Transportation, such as shuttle services
  • Adult day care
  • Personal care services

Nursing care center (also called skilled nursing care)

Care provided is short-term and similar to that given in a hospital. You will be given around-the-clock care.

  • Examples: Physical, occupational or speech therapy, Help with personal care and activities of daily living, Nursing care (nursing care can include changing bandages, giving medicines, and educating patients and their families about their condition, care and instructions.)


Hospice is usually provided in the patient’s home. Some patients need around-the-clock care in a hospice facility. The goal of hospice is to provide the best possible quality of life for as long as possible.

  • Support for family, end-of-life care, Nursing care  (nursing care can include changing bandages, giving medicines, and educating patients and their families about their condition, care and instructions.)