Home Preparation Checklist Before Discharge: Four Things to Settle Before Leaving Hospital

When the ward nurse tells the family that the patient can go home the next day and asks them to pack up, family members often think only of packing bags and calling a car home. But "packing bags" and "being ready for discharge" are two completely different things. A hospital bed has rails and handrails, and healthcare staff are on hand all day. Once the patient is back home, this support disappears at once. The real test of discharge is not the moment of stepping out of the ward, but whether each detail has been checked properly before leaving.

In short, four things must be settled before discharge: clearing hazards at home, getting aids in place, checking medicines and booking follow-up. Data show that structured discharge preparation can cut the readmission rate for older medical patients by about 11% (RR 0.89) and reduce hospital stay by about 0.73 days (Gonçalves-Bradley 2022), so nothing should be left until after going home. This article explains how to go through this checklist item by item before leaving, setting out the steps and the real figures in more detail than the main article on what to prepare for going home from hospital.

Why preparation should start before discharge

This is because the period just after a patient goes home has a fairly high risk of accidents. Forster and colleagues (2003) followed patients just after discharge and found that 19% (95% CI 15–23%) had an adverse event after leaving hospital, 6% of them preventable and another 6% with reduced severity possible. In other words, nearly half of the incidents were not unavoidable, and could be greatly reduced with enough preparation beforehand. Once the chance to prepare before discharge is missed, remedying it later costs much more.

By contrast, preparation made before leaving is supported by evidence. The Cochrane systematic review by Gonçalves-Bradley and colleagues (2022) (17 trials, 5,126 people) found that a structured, individually tailored discharge plan lowered the relative risk of readmission to RR 0.89 (95% CI 0.81–0.97) and shortened the first hospital stay by about 0.73 days (MD −0.73, 95% CI −1.33 to −0.12), with moderate-certainty evidence. The reduction is not dramatic, but the direction is very clear: doing the preparation up front does have a real effect.

Much of the preparation for discharge has to start during the hospital stay.Referral to community nursing, renting rehabilitation aids and booking follow-up all mostly need to be set going before discharge. If it is raised only on the day of discharge, or the follow-up is booked alone after going home, progress is often slowed. So the point of this checklist is not only "what to do" but "when to do it". Everything that can be settled before discharge should be dealt with during the hospital stay.

Four areas of preparation before discharge

Breaking down the preparation for discharge, it comes down to the four areas below. Each is supported by clinical evidence, and they are not things that merely "seem a good idea" but high-return measures confirmed repeatedly by several studies.

1. Clearing hazards at homeFirst put away loose rugs at home, clear thresholds, clutter and extension cables, and fit handrails and improve lighting at night. Research shows that having a therapist remove obstacles in the home can lower the fall rate by about 38% (Stark 2021). If, before discharge, routes for everyday walking are planned in advance using a plan of the patient's home, the rate of near-falls after discharge can fall from 26.9% to 3.7% (Ueda 2022).

2. Getting aids in placeAids such as a wheelchair, walking frame, bedside commode, shower chair and handrails must be confirmed before discharge to be the right size and to have room at home, so that the patient can use them straight away on coming home. Homes in Hong Kong are generally small, and it often happens that "the aid was bought and brought home, only to find it cannot be pushed into the bathroom".

3. Checking medicinesAt discharge, collect all the medicines and check them one by one: be clear which old medicines to stop, which ones are newly prescribed, and which ones have a changed dose. Research shows that as many as 66% of adverse events after discharge are related to medicines (Forster 2003). This step is the easiest to get wrong, so take the time to check carefully.

4. Follow-up and aftercareBefore discharge, fix the follow-up date and the specialty clinic, arrange the community nursing referral, and ask which warning signs in the body to watch for. The Project RED study showed that when follow-up was arranged before discharge, 94% of patients left with an appointment slip (against only 35% in the control group), and their later rates of readmission and visits to the emergency department were also clearly lower (Jack 2009).

Planning routes and clearing hazards from a plan of the home

The first preparation should start from the patient's "daily routes" and not from a complete renovation of the home. The strongest medical evidence at present is mainly about removing immediate hazards in the home. In the randomised controlled trial by Stark and colleagues (2021) (310 people, 12 months of follow-up), after occupational therapists visited homes, removed thresholds and loose rugs, fitted handrails and improved lighting, the fall rate among older people fell significantly by 38% (RR 0.62, 95% CI 0.40–0.95, P=.03; 1.5 falls per person-year in the intervention group against 2.3 in the control group). The improvement therefore lies in "the routes the older person actually walks every day" and not in a major renovation of the whole home.

More important, this preparation can begin before the patient goes home. In the trial by Ueda and colleagues (2022), healthcare staff gave targeted guidance to older orthopaedic patients before discharge using plans of their homes, and the rate of "near-falls" after discharge fell sharply from 26.9% in the control group to 3.7% in the intervention group (P=0.018), while the actual fall rate fell from 4.3% to 0%. In other words, planning with a plan of the home before leaving, such as where handrails are needed and where clutter should be cleared, is already a very effective fall prevention intervention. The items that most often need attention are below.

Clearing hazards at home: check item by item before leaving

Check the route from the bed to the toilet at night, put away loose rugs, and clear thresholds and extension cables
Fit sturdy handrails beside the toilet, in the shower area or by the bathtub, and lay non-slip mats on the floor
Put a night light and a telephone by the bed, so the older person does not have to walk in the dark when getting up in the night
Put commonly used things such as the water cup, medicines and remote control at a height between the waist and the shoulders, so the older person does not lose balance by bending down or raising both arms to reach them
Use a plan of the patient's home to plan beforehand the routes for everyday walking and the positions for fitting handrails (Ueda 2022)
Do not wait until the patient is home to tidy up slowly, or the home will lack safety measures in the first few nights after returning, which are the most dangerous

Living conditions in Hong Kong have their own difficulties. For example, many tenement buildings and older private buildings have no lift and narrow stairs, and a walking frame may not be able to be carried up. Whether the patient needs someone to hold on when going up and down the stairs on coming home, and whether a temporary stair handrail or extra help is needed, must be asked beforehand. In addition, toilets in small and medium-sized flats mostly have no separation of wet and dry areas and no handrails, and this is the most common fall black spot in local homes. Whether a shower chair, non-slip mats and toilet handrails are ready should be assessed before discharge. For a more systematic approach to preventing falls by working on the home environment, see the key points of environmental assessment in the article on fall prevention and balance training at home after discharge.

How to check medicines before discharge

Of the four areas of preparation, checking medicines is often the least conspicuous but the easiest to get wrong. Forster and colleagues (2003) analysed adverse events after discharge (n=400) and found that as many as 66% were adverse drug events, meaning that the harm patients most often meet after leaving hospital is taking the wrong medicine. The reason is not hard to see. During a hospital stay the doctor usually makes big changes to prescriptions, so the medicines handed out at discharge can be quite different from those before admission. The mistakes most likely at home are taking old and new medicines twice over, or forgetting to stop an old medicine.

Ask how to take each medicine, one by one

Which medicine is newly prescribed? Why must it be taken, and for how long?
Which medicine needs to be stopped? (An old medicine taken for a long time before admission is the one most easily forgotten to stop at home)
Which medicine has a changed dose or number of times a day? Should it be taken before or after meals?
Among these medicines, are there any two that must not be taken together?

The last check before leaving the ward

Make sure you hold a clear and up-to-date medicine list
Sort the medicines into a pill box beforehand or stick clear labels on them, and never rely on memory to take medicines
Ask what to do if a dose is missed, and which side effects mean medical help must be sought at once
If a blood test or other tests are needed before the follow-up appointment, ask the healthcare staff about this too

Using the teach-back method to confirm instructions from healthcare staff

Even with the three kinds of preparation above, one last step is missing: confirming that family members really understand the details, and not just nodding and saying "mm-hmm" as if they had understood. This method is called "teach-back". After the healthcare staff have finished explaining, the family member repeats it in their own words, and any misunderstanding can be corrected on the spot. The Project RED study led by Jack and colleagues (2009) combined teach-back, medicine review and follow-up arrangements, and showed that it effectively lowered the rate of readmission and emergency department visits within 30 days of discharge (utilisation IRR 0.695, 95% CI 0.515–0.937, P=0.009).

Before leaving, family members can try repeating each of the following sentences to the nurse in their own words.

"What he needs to take tonight is..."—Repeat to the healthcare staff which medicines are new, which are to be stopped and which have a changed dose. Only when it can be said accurately has it really been checked.
"If he gets..., I must call the doctor / go back to hospital at once"—Repeat each danger sign (such as fever, a red, swollen or pus-filled wound, breathlessness, a sudden drop in alertness, an unexplained fall) to make sure it is clear which situations are red lines for seeking medical help.
"The next follow-up is..."—Repeat the follow-up date, specialty clinic and place, and while at it confirm whether a blood test or other tests are needed before the follow-up.
"If anything happens, I can call..."—Repeat the follow-up contact number of the community nurse or the ward, so that the family knows how to reach the right people if something sudden happens after going home.

A printable checklist for before discharge

The four areas are put together below as a list to go through one by one before leaving. Completing this list is not only for peace of mind. Research shows that discharge preparation led by nurses, making sure follow-up appointments and medicine review are carried out, is closely related to a lower readmission rate (Jack 2009; Naylor 1999).

Checklist before discharge

The routes normally walked at home have been cleared, and handrails, non-slip mats and night lights have been fitted
The aids needed (for example a wheelchair, walking frame, shower chair or commode) have been rented, and there is enough room at home to put them and use them
The latest medicine list has been received, checked one by one without problems, and the medicines have been sorted into a pill box beforehand
The follow-up date, specialty clinic and place have been fixed, and the follow-up appointment slip has been received
During the hospital stay, the referral process for community nursing or community care services has been started
The "teach-back" method has been used to confirm with healthcare staff that the danger signs and the emergency contacts are understood

When using this list, it is advisable to read it together with the article on why carers should not do everything for the patient after discharge. This checklist mainly deals with the "home environment and discharge process". How family members should support the patient after going home, and when to let go and let the patient move alone, is another key to maintaining the patient's physical function.

Renting aids in Hong Kong and arranging a home assessment

To put the second item, "aids in place", into practice in Hong Kong, the most practical thing is to know where equipment can be rented and who does the environmental assessment. Several non-profit organisations in Hong Kong provide rehabilitation equipment rental: the Hong Kong Red Cross mobility aids rental service (2610 0515, with no age limit), the 復康資源協會 specialist centre (2364 2345) and the 香港輪椅輔助隊 (2194 9666). In addition, the Jockey Club 「a家」 gerontech education and rental centre (3153 5252) also serves older people. To assess the home environment first before deciding which equipment to buy, the patient can apply for a referral through the hospital's patient resource centre or the medical social worker. The Hospital Authority's discharge planning in itself already includes a home environment assessment by physiotherapists and occupational therapists.

In practice, the first job of a therapist on a home assessment is usually to walk through the patient's daily route (from the bed and toilet to the front door), measure the right positions for fitting handrails and clear away clutter that could trip the patient, and not to begin exercise training as soon as the patient is back home. The principle of "remove hazards first, then train" must be kept in mind: only when safety measures are in place at home can the walking ability the patient has worked hard to regain be used safely. Otherwise, the first two weeks after discharge are often the high-risk period when falls at home are most likely. Another common trap is the size of equipment. Space is precious in Hong Kong and homes are small, so it is not rare to buy an aid and find there is nowhere to put it. Therapists therefore usually ask family members to take photos of the toilet, bedside and front door at home before the patient is discharged, so that the right model of shower chair and walking frame can be chosen beforehand and handrail positions planned, avoiding finding out after discharge that the walking frame cannot be pushed into the toilet.

If, after discharge, family members find that the patient clearly struggles more than before admission to get up and walk to the toilet, or cannot judge which aids are suitable and which route at home is the most dangerous, these are clear signs to seek a professional assessment. The home physiotherapyand occupational therapy services provided by Nova Health have registered therapists visit to assess the home environment and the patient's real mobility, helping family members put the checklist above into practice item by item, so that the patient is properly supported during the most vulnerable stage of the transition after discharge.

Key points

Four things must be settled before the patient is discharged: clearing hazards at home, getting aids ready, checking medicines and booking follow-up. Research shows that structured discharge preparation can lower the readmission rate by about 11% (RR 0.89) and reduce hospital stay by about 0.73 days (Gonçalves-Bradley 2022).
Clearing hazards at home should start with the routes normally used. Targeted removal of hazards can lower the fall rate by about 38% (Stark 2021). If, before discharge, routes are planned in advance using a plan of the patient's home, the rate of near-falls can fall sharply from 26.9% to 3.7% (Ueda 2022).
Checking medicines is the step most likely to go wrong. Research indicates that 66% of adverse events after discharge are related to medicines (Forster 2003), so before leaving hospital it is essential to check one by one which medicines to stop, which are new, and which have a changed dose.
Follow-up appointments and aftercare must be settled before discharge. Research shows that when follow-up was arranged before discharge, as many as 94% of patients left with an appointment slip, and their later rates of readmission and emergency department visits were lower (Jack 2009).
When listening to healthcare staff, use the "teach-back" method to say the key points back yourself, to make sure you really understand, and do not simply nod and say "mm-hmm". In Hong Kong, rehabilitation aids can be rented from organisations such as the Red Cross (2610 0515), and family members can arrange a home environment assessment through the hospital's patient resource centre or the medical social worker.

Frequently asked questions

Must all the fittings at home be changed before discharge?

No big renovation is needed. The strongest evidence suggests the key is removing immediate hazards: moving away loose rugs, clearing clutter that blocks the way, fitting handrails in the toilet or by the bed, and improving lighting at night. Having an occupational therapist remove hazards in the home can already lower the fall rate by about 38% (Stark 2021). The point is to clear the "routes the patient uses every day" and not to renovate the whole home.

A big bag of medicines comes with discharge. How can I check them so nothing is taken wrongly?

The most common harm to patients after discharge is related to medicines, making up as much as 66% of adverse events (Forster 2003). Before leaving, family members should go through the medicines one by one with healthcare staff: which ones to stop, which ones are new, and which ones have a changed dose. Then use the "teach-back" method to repeat it to the nurse, to make sure it is fully understood, and never just nod and say "mm-hmm" as if it were understood.

When should the follow-up appointment be settled?

The follow-up appointment should be settled before discharge and not left to arrange after going home. In the Project RED study, as many as 94% of patients who had a follow-up arranged before discharge left with an appointment slip (against only 35% in the control group), and their rates of readmission and emergency department visits within 30 days were clearly lower (Jack 2009). The step is only really done when the follow-up appointment slip is in hand before leaving.

Where in Hong Kong can I rent a wheelchair, walking frame or bedside commode?

Several non-profit organisations in Hong Kong provide rehabilitation equipment rental, including the Hong Kong Red Cross mobility aids rental service (2610 0515), the 復康資源協會 specialist centre (2364 2345) and the 香港輪椅輔助隊 (2194 9666). The Jockey Club 「a家」 gerontech rental centre (3153 5252) also serves older people. Family members can first ask the hospital's patient resource centre or the medical social worker about the referral procedure.