A guide to post-hospital care for the elderly

Post hospital care for older adults

A hospital stay can be a difficult time for anyone, and this could be especially challenging for older adults whose routine has been disrupted, and who require ongoing care afterwards. Although time in hospital is designed to help with recovery from an accident or illness, often there is an additional period of recovery after hospital in which the person must adhere to certain medications, follow-up appointments, physical therapy exercises, dressing changes and more, depending on their condition. 

Here, we are exploring the importance of hospital aftercare to prevent complications, common post-discharge challenges, the best ways to manage post-hospital medication needs, the rehabilitation options available, the emotional support needed, how loved ones can support older adults, and how professional home care workers can help.

At Home Instead, our aim is to help people age positively and in place by bringing expert care to their home. For nearly 20 years, we have been providing the highest standard of care, and creating industry-leading training programmes for our Care Professionals that are accredited by nursing and medical professionals. Today, we are the world’s largest global domiciliary care network, supporting over 100,000 older adults with personalised, tailored care at home. So whatever questions you have about post-hospital care for older people, we can help.

What are the common challenges older adults experience post-discharge?  

After hospital discharge, older adults often face several challenges that can make their recovery more complicated and stressful, such as:

• Medication management, if they struggle with complex regimens, forget doses, or face unpleasant side effects.
• Mobility difficulties, especially after surgery or a particularly bad illness that leaves them bed-bound for a time, as this could have affected their strength or balance, increasing the risk of falls. They may also struggle with daily personal care tasks, and require help. You can read more in our guide to common mobility problems in older people
• Emotional struggles, such as anxiety about managing their condition, depression, lack of confidence, or isolation post-discharge. Isolation can be more intense if they feel unprepared or lack adequate support at home. You can read more in our guide to the signs of loneliness in older people
• Not having help for medical monitoring, which is often required for older adults who have just left hospital. This is designed to ensure conditions like hypertension, diabetes or heart disease are monitored and get the required check-ups.
• Fatigue, as a result of a prolonged stay in hospital which may have affected their sleep and energy levels.

Getting adequate and effective post-hospital care can be difficult for older people who live alone and do not have anyone to help them with the above needs. In some cases, older people may end up stuck in hospital due to a lack of support. In fact, according to the Age UK 2023 State of Health and Care report, this lack of sufficient care can contribute to overcrowding in hospitals, delayed discharge, and other issues. It is thought that over the winter period of 2022/23, around 13,000-14,000 patients were stranded in hospital on any given day, with many waiting for a package of social care to be put in place either in their home or in a care home.

What post-hospital rehabilitation options are available to older adults? 

There are several post-hospital rehabilitation options to support the recovery of older adults after a hospital stay, and improve their independence. These might include things like physical therapy, which can help the person regain strength, flexibility, dexterity and movement. As an example, in one 2015 study, patients who had undergone surgery for a knee replacement and were receiving physical therapy experienced improved physical function at 3-4 months, compared to control groups. 

Older adults may need specific help and care to recover from a surgery, fall, a medical condition like stroke, or something else, and this care could be on a short-term basis (known as intermediate or reablement care) or could be more extensive. Home care, as opposed to a care home, is thought to reduce the risk of hospital readmission, with one 2022 study finding home care reduced readmission and the length of hospital stays in those with advanced heart failure. 

Reablement caremight be used to help people regain the ability to manage their daily activities independently, and avoid readmission to hospital. This can come in the form of care from your local council or private home care, depending on your needs, and can involve a number of daily activities such as helping with personal care tasks, housework, cooking, attending GP appointments and more. If the person needs ongoing medication management or health monitoring, professional home care can help with this too. 

Reablement care is similar to regular home care, however it differs in the fact that it is often a short-term arrangement that aims for a specific health and wellbeing goal, instead of a long-term, ongoing care arrangement. Reablement is thought to lead to improved health outcomes, better wellbeing, less time in hospital, and more autonomy in recovery, according to research. 

You may learn more useful information about this in our article: Reablement Care For Older Adults

Many people only require reablement care for a couple of weeks, but this is usually available through the NHS free of charge for up to six weeks, after which time the person would be required to pay towards this. The hospital discharge team can create a referral for you if you need reablement care, or they may suggest NHS Continuing Healthcare, which is another process that may be activated by either the hospital discharge team or your local council to offer a package of ongoing NHS health and social care. You can read more about this in our guide to what a Continuing Healthcare Checklist is.

How can older adults manage with impaired mobility after a hospital stay? 

If you (or your loved one) struggle with mobility after a stint in hospital, you may also need additional support such as:

• Physical therapy to regain strength, balance, flexibility, mobility, and to reduce the risk of falls
• Assistive devices such as walkers, canes or wheelchairs to offer stability and independence
• Home adaptations such as grab bars, ramps and stairlifts to make the living environment safer and more accessible if you cannot easily move around at home 
• Professional home care to help with daily activities like dressing, bathing and moving from A to B in the home 
• Gentle exercise routines tailored to your capabilities to promote gradual improvements in physical health 

If you are looking after a loved one who is recovering from a fall, keep in mind that gentle exercise can be helpful in building up their confidence again. Often older people fear falling a second time, and this may be the case if the person shows signs of isolating themselves or avoiding physical activity. This leads to them becoming physically weaker, which can increase the likelihood of experiencing another fall. For this reason, gentle exercises – if advised by medical professionals – are extremely important, with one 2023 study suggesting light physical activity after a hospital discharge can improve recovery in acutely hospitalised older adults. 

How can older adults effectively manage medication after a hospital stay? 

When you leave hospital, you may have a number of medications to take in order to continue recovering at home. Effectively managing these medications usually requires various strategies. Here are some of the ways this can be done without making mistakes:

• Take time to understand your needs before you leave hospital – if you are leaving an NHS hospital, speak to the discharge team, your doctor, the pharmacy team or a nurse to establish exactly what medications you should take, how much, and when. You will usually be given at least 2 weeks’ supply if needed, with instructions of how to get any further medication. You should also be given a discharge letter which details this information so you can refresh your memory at home. 
• Use a medication organiser like a pill box or blister pack to ensure you are always taking the correct dosages at the right times. You can learn more about this in our guide to easier medication management using blister packs.
• Set up reminders on your watch, phone alarms, home devices or on an app to make sure you do not miss doses or take too much. 
• Use assistive technology such as automatic medication dispensers, which can give families peace of mind that their loved one is taking the recommended medications and doses at the right times
• If you experience any side effects or have any questions, do not hesitate to review your medication routine with a healthcare provider (either your GP or the prescribing hospital doctor if you have contact with them) to better understand what you are taking and to avoid interactions. 
• Involve a caregiver or family member if you need to. It can help to have them understand and keep track of your medication by being a second set of eyes. They may also be able to help with more complex medication regimes.
• Book in regular follow-up appointments with your GP to allow for adjustments to prescriptions, and ensure your medication plan remains safe and effective during your recovery from hospital. 

How important is emotional support for post-hospital recovery? 

Emotional support is a crucial part of the post-hospital recovery experience, particularly for older adults who may live alone. After a stay in hospital, many patients can experience feelings of anxiety, loneliness or depression as they adjust to new routines, physical limitations, or health concerns. 

Having appropriate emotional support from family, friends and caregivers can significantly enhance their mental wellbeing, which can in turn support their physical recovery. A 2023 study found over two thirds of patients and caregivers said family and friends were very important sources of emotional support, while others said nurses, doctors, psychologists and psychiatrists were important. 36% of study participants reported experiencing insufficient levels of support which were linked to feelings of distress.

Positive emotional support can promote motivation, encourage older adults to adhere to their medication schedules, support them in attending rehabilitation appointments, and keep them active throughout their recovery. This can also reduce the risk of complications due to stress. Whether this support comes from family, community support or professionals, it could be vital for the patient’s physical recovery as well as their mental health. 

One study identified patients leaving hospital can benefit from a combination of empathy, informative communication, people being present and available, inspiration and hope, personalisation, supportive gestures, humour, and an ambient environment. This would suggest recovering from a hospital stay at home – with the help of either a family caregiver or professional home carer who can dedicate time to helping – can provide the robust emotional support system needed to foster a healthy recovery.

You may find more helpful information in our guide to supporting mental health in older adults.

Keep in mind, emotional support may also be important for those who have not yet left hospital, as NHS monitoring data suggested a 30% increase in patients facing delays when leaving hospital between December 2021 and August 2022. With the increased burden on NHS services, older adults and their caregivers should also be prepared to provide the appropriate support while they remain in hospital. 

How can I help my loved one after their hospital stay? 

Often, older adults will be entitled to reablement care after a hospital stay. Reablement care can be arranged by the hospital discharge team or your local council, and is usually free for up to six weeks to help an individual regain independence at home. If after this they require ongoing care, they will need to arrange a financial assessment to determine what support is available and how much of it will be paid for. 

Whether or not reablement care takes place, if you have an older relative in hospital you may wish to help, and there are a number of ways to do this:

• Be part of their hospital discharge process so you understand their needs going forward and can support them when they get home.
• Help to organise appropriate transport home from hospital. You can learn more about this in our guide to arranging transport to and from hospital for older adults.
• Offer practical help around the home, with things like personal care or housework.
• Understand what is needed for reablement care and how you can help around this. Studies find reablement care is usually helpful for family caregivers when they have a good understanding of their role and the goals their older loved one is working towards.
• Talk to your loved one’s doctors about whether it is best they remain in their own home or are moved to an appropriate care home. Schedule regular visits to make sure they know you are nearby and available for anything they are worried about.
• Talk to them about how they are feeling, and provide emotional support if there is anything they are worried about.
• Encourage them to plan social interactions to avoid isolation and loneliness, whether that means helping them have friends over to visit or going somewhere to meet them, as long as this is safe during their recovery.
• Help them stay on top of medication schedules and follow-up healthcare appointments.
• Make use of assistive technology like fall alarms or motion sensors to ensure your loved one is safe at home when left alone, and can get a speedy response if they fall or have an accident
• Ensure the home is safe and comfortable for them by making any adjustments to reduce fall risks or remove hazards.
• Arrange home modifications such as grab bars or ramps if they have mobility issues after their hospital stay, and support them in moving around the home safely. You can learn more in our guide to home adaptations for disabled older people.
• Support them with physical therapy or balance exercises to improve strength, stability and coordination as they recover. If it has been recommended that they do some physical exercise, you can read more in our guide to fitness and exercise for older adults.
• Coordinate with professional home care services or rehabilitation providers if they need to arrange visits.

How can professional home carers help with post-hospital care? 

Professional home care can play a crucial role in the post-hospital needs of older adults or those with complex health issues. Home care services can provide personalised assistance tailored to the patient’s condition, and can help with things like medication management to ensure prescriptions are followed correctly, monitoring for any complications, or helping around the home until the person is back on their feet.

For example, in the case of older people with mobility issues, caregivers can assist with daily activities such as bathing, getting dressed, and moving around the home safely to reduce the risk of falls. They may also be able to provide encouragement for physical therapy exercises and healthy lifestyle changes, such as a healthy diet or gentle exercise, which can aid in recovery. If required, more specific care needs can also be met, such as wound care or vital signs monitoring.

Additionally, and importantly, home care professionals can also offer emotional support to help older individuals manage the psychological challenges of recovery after being in hospital – such as anxiety or loneliness – and help them to set achievable recovery goals. 

If you are looking to enlist the help of a professional home carer during your loved one’s reablement care after a hospital stay, there are many home care options available to help. Feel free to get in touch with your local Home Instead office to learn more, or read our guide on choosing and arranging home care for a step by step guide on everything you need to know about organising this.

Our Care Professionals are the best of the best, and highly trained to deliver the services you need. No matter what type of home care you are looking for, we can provide a tailored service that suits you or your loved one. 

We’re an award-winning home care provider and part of a worldwide organisation devoted to providing the highest-quality relationship-led care for older people in their own homes. Arranging care for yourself or your loved one shouldn’t be stressful, so whatever questions you would like answered, feel free to reach out to the Home Instead team to discuss your needs.