When the ward nurse phones to say that mother can go home today, the family's first reaction is often relief, feeling that the hospital stay has at last been got through. The real test, however, starts from the moment the person walks out of the hospital doors. Before admission the older adult could still walk to the toilet alone, but after two weeks in hospital, back at home, the person cannot stand steadily even holding the bed rail, needs help to put on clothes, and almost falls getting out of bed in the middle of the night. Only then does the family realise: why has the body got worse, and not better, after the illness was treated and the person was discharged?
This is not an illusion on the family's part, and it does not mean the care was poor. After leaving hospital an older adult goes through a "fragile period", because the hospital stay itself weakens bodily function. The study by Covinsky and colleagues (2003) found that 35% of older adults had worse ability in daily self-care at discharge than before admission, and in those aged 90 and over the proportion was as high as 63%. The focus of care in the first weeks at home is therefore "support and not doing it for the person", a safe home set up properly, and an immediate link to Hospital Authority community nursing (which can generally visit within a few days of discharge). The sections below start with the fragile period and then go through discharge preparation, home arrangements and links to community services.
Understanding the fragile period after discharge
Many families overlook a fact: what takes away an older adult's self-care ability after discharge is often not the illness that led to admission, but the "hospital stay" itself. Krumholz (2013) called the stage just after discharge "post-hospital syndrome", an acquired, transient state of generalised risk that develops during the hospital stay. Disturbed sleep routines, poor nutrition, deconditioning from bed rest, and changes in medicines during the stay all raise the risk of readmission and adverse events sharply, and the problem usually has no direct link with the original cause of admission.
How common is this fragile state? Data tracking hospitalised older adults from Covinsky and colleagues (2003) show that 35% of patients overall had worse ADL self-care ability at discharge than before admission. Of these, 12% were new losses of function during the stay, and the other 23% had already declined before admission and did not recover during the stay. The older the person, the more common it is: the proportion with functional decline rises from 23% at age 70–74 to 50% at age 85–89, and reaches 63% in those aged 90 and over.
What to watch is whether function has dropped, and not whether the illness is cured.Many families think that being allowed to go home means full recovery, and so lower their guard. The real high-risk period is the first month after discharge, when readmission and falls are most likely. Instead of only asking whether the disease has gone, the family should watch closely whether the patient's alertness, appetite, fluid intake and daily activity are gradually coming back.
Discharge preparation checklist for the day before going home
Fortunately, the fragile period after discharge is not something that cannot be dealt with. The Cochrane systematic review by Gonçalves-Bradley and colleagues (2022) found that a discharge plan tailored to the patient slightly reduces the chance of readmission (the relative risk of readmission within about three months falls to RR 0.89, 95% CI 0.81–0.97) and slightly shortens the hospital stay (by an average of 0.73 days), and also raises patient satisfaction. A fuller intervention works better. The randomised controlled trial by Naylor and colleagues (1999) showed that comprehensive discharge planning led by advanced practice nurses, together with home follow-up (transitional care), cut readmission from 37.1% in the control group to 20.3% in the intervention group (P<.001), and cut medical costs over 24 weeks by about half.
The key is that such planning cannot depend on the hospital alone, and the family also needs to ask the healthcare team before discharge. In practice it comes down to four areas to check one by one before leaving: clearing hazards at home, having aids ready, checking the medicine list, and confirming the follow-up appointments, and also asking whether the hospital has referred the patient to community nursing. The earlier these four tasks are done before discharge the better, because referral to community nursing mostly has to be started in the hospital, and applying after the patient is home takes more time. For the specific steps, a printable checklist and the hotline for renting aids, see the checklist of four areas of home preparation before discharge.
Arranging the home environment for coming home from hospital
In hospital the patient sleeps in an adjustable bed with bed rails, and there are handrails all around to lean on. Once back home, the environment changes from one "designed for rehabilitation" to an ordinary living layout. The principle for tidying the home is quite direct: follow the route the patient uses most, from the bed to the toilet and from the toilet to the living room, and clear obstacles section by section and add firm support. The items most often dealt with at a home assessment are as follows:
- Remove loose rugs and cables on the floor—On the way from the bed to the toilet there are three common tripping hazards: rugs that do not lie flat, thresholds and extension cables. When we visit for an assessment in the first week after discharge, we almost always have to clear this route first.
- Handrails and non-slip mats in the toilet and bathroom—Handrails should be fitted beside the toilet and by the shower or bath, and non-slip mats laid on the floor. If the shower area is too narrow for a standard handrail, a clamp-on or suction handrail can be considered, but it must first be checked that it can bear the load, and the whole body weight should never be put on it.
- A night light and a telephone by the bed—An older adult getting out of bed in the dark at night easily falls. Put a night light by the bed and keep the telephone within easy reach, so that help can be called straight away after a fall.
- Keep everyday items at a height that needs no bending or reaching up—Cups, medicines, tissues and the remote control are best kept at a height between the waist and the shoulder. An older adult just home from hospital has not regained balance, and squatting down or reaching up to get something easily upsets the centre of gravity.
- Check whether the bed is too low or too soft—At home assessments, the most common problem is a bed that is too low or a mattress that is too soft, which makes it very hard for the patient to get up. When the person sinks in too deep on sitting down, it is hard to find the strength to push up. Doing this dozens of times a day not only wastes energy but also makes falls likely.
Hong Kong's living conditions have their own particular difficulties. Old tenement buildings and older public housing have no lift and the stairwells are narrow, so the first hurdle for an older adult coming home in a wheelchair is the stairs, which often means arranging a stair lift in advance or finding people to carry the person up and down together. Space in local flats is also limited, and between the bed and the toilet there is often clutter and loose rugs, which make that stretch a high-risk route for falls after discharge. The toilet in a subdivided flat or a very small unit is often too narrow to fit a standard handrail, and then a clamp-on solution must be used and the load it can bear assessed in advance. To approach fall prevention more systematically by improving the environment, see the points on environmental assessment in the article on home fall prevention and balance training after discharge.
Why too much help from carers makes the patient worse
In daily care, the most counterintuitive but most real situation is this: in the fragile period after discharge, the more the family helps, the faster the patient may decline. Out of tenderness, families often rush to dress the patient, support every step, and do everything for the person. The longer the patient is looked after, the fewer chances to move alone, and in the end the patient falls into a vicious circle of dependence on others. In fact, whenever the family does a movement that is within the patient's ability, the patient loses one chance to practise.
"Watching nearby" does not mean "doing everything".Whatever the patient can do alone in daily life, such as eating, dressing and walking to the toilet, should be left to the patient, and the family only needs to stand by and watch for safety. Boltz and colleagues (2014) tested "family-centred function-focused care" (Fam-FFC), which teaches family members to encourage the patient to handle daily activities alone and not to do everything. The research showed that this left carers better prepared and also helped the patient to regain the ability to move. In contrast, if the patient is restricted for fear of a fall, or because of the idea that "more bed rest means faster recovery", and everything is done for the patient, the patient only becomes more and more dependent.
When handing over care, therapists often remind families that whatever the patient can do alone should be left to the patient while the family stands by and watches. Allow a little more time and patience so the patient can finish the movement by hand. Even if putting on one garment takes ten minutes longer, what is gained is the preservation of bodily function. Exactly where to step in with support and where to let go in the three most common situations of daily meals, going to the toilet and walking is hard to set out in one rule. See the article on the line between helping and over-helping for the details of each. To learn what rehabilitation exercises can be done at home after discharge and how to raise the training load step by step, see progressive rehabilitation exercise at home after discharge. This page concentrates on how to care and on the home environment, and does not go into the exercise details.
Linking up with community rehabilitation services after leaving a public hospital
Discharge is not the end of the rehabilitation course. It is a relay in which the place of rehabilitation moves from the hospital to the community. In research, the Cochrane systematic review by Langhorne and colleagues (2017) found that "early supported discharge" delivered by a well-coordinated multidisciplinary team (that is, moving hospital rehabilitation into the community or the home) effectively reduces long-term disability: the odds ratio for death or dependence was 0.80 (95% CI 0.67–0.95), the hospital stay was also shortened by about 6 days on average, and there was no negative effect on the mood of patients or carers. This shows that the "discharge transition model" has definite evidence behind it. For how recovery should progress after the transition and how long each stage takes, see the timeline of the recovery stage after discharge.
Returning to the Hong Kong medical and social welfare system, the most practical thing is to be clear about which community routes already exist and how to start an application. Besides the Hospital Authority community nursing and Social Welfare Department hotline described below, which are used most often, there are also the Social Welfare Department's Day Community Rehabilitation Centres (CRDC), geriatric day hospitals and the community rehabilitation network (CRN) of the Hong Kong Society for Rehabilitation, each of which takes in a different type of discharged patient. For how to sort and choose the right route, see the four relay lines of community rehabilitation after discharge in Hong Kong:
| Hospital Authority Community Nursing Service (community nursing team) | Referred by the doctor in the ward or outpatient clinic. There is generally no waiting list, and a nurse can visit within a few days of discharge to deal with wounds, stomas, catheters, diabetes and stroke rehabilitation guidance. The public hospital charge is about $80 a visit, and those in financial difficulty can apply for a waiver through the medical social worker. For example, the Tuen Mun Hospital community nursing team 2468 5713 (Monday to Friday 9:00–17:00, Saturday 9:00–13:00). |
| Social Welfare Department hotline 2343 2255 | The hotline has a 24-hour recorded system for enquiries about welfare services. Social workers answer Monday to Friday 9:00–17:00 and Saturday 9:00–12:00. Families can phone to ask about community care services such as integrated home care, District Elderly Community Centres and day care for the elderly. |
| Medical Social Services Units of hospitals in each district (medical social workers) | Before the patient leaves hospital, a medical social worker can help with medical fee waivers, referral to community care services and support for carers. If a waiver of community nursing charges or the arrangement of community care services is wanted, going to the medical social worker before discharge is the most convenient way. |
| Self-paid home physiotherapy and nursing | The number of training sessions that a public hospital's community service or day hospital can give is limited. If the patient needs more training in the fragile period after discharge, the family can arrange a self-paid private home service, so the patient practises in his own home. If the patient is discharged after an operation, the guidance for going home after surgery can be consulted for rehabilitation arrangements and points to note. |
If the patient is discharged after an operation, the link-up to community services and the daily points to note differ a little, and the article on physiotherapy arrangements after discharge from surgery is advised for comparison. To see where the discharge transition sits in the whole course of "recovery after long-term bed rest", go back to the overview of recovery after a long hospital stay.
Care priorities for the first four weeks after discharge
Finally, the steps above can be strung into a timeline. The first four weeks after discharge are the core of the whole fragile period, and each week has a different care focus, moving from arranging the service link-up and setting up the environment at the start to rebuilding daily activity:
The timeline above is for general reference only. Because each patient's condition, age and home environment differ, the speed of recovery naturally varies a great deal, and the actual pace should be adjusted according to the assessment of the healthcare team and the therapist.
When to ask a therapist for help
If, after discharge, the family finds that getting up from bed and walking to the toilet is clearly harder than before admission, or that in the first week or two at home there is no progress and the patient keeps slipping back, or the carer cannot judge "how much help should be given", these are all situations worth a professional assessment. With the home physiotherapyof Nova Health, a registered physiotherapist assesses the home environment and the patient's real abilities on site, helps the family sort out which movements need support and which should be left to the patient, and adjusts the amount of training to the needs of the fragile period, so that the best window for recovery during the discharge transition is not wasted.