The 30-Day Readmission Risk Window: The first 30 days after hospital discharge are the highest-risk period for older adults. Roughly 1 in 11 Canadian patients are readmitted within 30 days, and for seniors that number is significantly higher.
Post-Discharge Risks to Watch For: Falls, medication errors, infections, and missed follow-up appointments are the four most common risks seniors face after leaving the hospital. These are preventable with the right preparation.
Questions to Ask Before Leaving the Hospital: Before discharge, caregivers should ask the care team about diagnosis, medications, warning signs, wound care, activity restrictions, and follow-up appointments, and write everything down.
How to Fall-Proof a Home: Remove tripping hazards, add grab bars in the bathroom, consider a shower chair and raised toilet seat, and ensure stairways are well-lit with sturdy handrails on both sides. Having a medical alert system can add an extra layer of protection.
———
When preparing for hospital discharge for an older adult, one of the most important things you can do is make appropriate preparations before they leave. A safe post-hospital recovery starts with understanding discharge instructions, preparing the home for their arrival, managing recovery treatment correctly, and knowing what warning signs to watch out for, all before they walk out of the hospital.
In Canada, roughly 1 in 11 patients is readmitted to a hospital within the first 30 days after discharge. For older adults, that number is even higher. The first 30 days at home hold the greatest risk of complications and preventable health setbacks. Having a solid hospital discharge plan is important for a successful recovery at home.
As a caregiver preparing for your loved one’s hospital discharge, you’re likely navigating a lot of paperwork, new medical terms, and decisions that need to be made fast. You’re not alone in feeling that way. Hospital discharge is an important and often stressful period for caregivers and older adults. The days and weeks right after leaving the hospital carry a higher risk of complications, hospital readmissions, and avoidable health setbacks. But here’s the good news: with a little planning and the right information, you can set your loved one up for a much smoother recovery.
This guide is written for caregivers who are on the front lines of making sure their loved one gets home safely and stays that way.
Facts about Hospital Discharges in Canada
A hospital discharge in Canada is more common and more complex than many people realize. Canada has one of the highest hospital readmission rates among developed countries. According to the Canadian Institute for Health Information (CIHI), roughly 1 in 11 patients is readmitted to hospital within 30 days of discharge, and for seniors, that number is significantly higher. The first 30 days after discharge are also the highest risk window for older adults. Seniors are more vulnerable to post-discharge complications due to factors like multiple chronic conditions, having to take several medications at once, reduced mobility, increased fall risk, and social isolation.
The responsibility for coordinating post-hospital care most often falls heavily on family caregivers. It is not unusual for family members to call for more help, particularly from local services that can help provide better support. Home care services vary widely by province. Home care services available in Ontario or British Columbia may look very different from what’s offered in Manitoba. Understanding what public support exists in Manitoba and where the gaps are is an important step.
The discharge process may feel rushed as well. Studies show that some patients and caregivers feel they weren’t given enough information before leaving the hospital, which can cause confusion, missed follow-ups, and preventable setbacks. Understanding this right from the start means you can advocate more effectively and ask better questions to set yourself and your loved one up for success.
Top Risks After Hospital Discharge
Returning home after a hospital stay is an important milestone, but recovery doesn’t end at discharge. Being aware of common risks can help older adults and caregivers support a safer recovery and reduce the chance of returning to the hospital.
Falls
Many older adults are at a higher risk of falling when they first return home from the hospital. While in the hospital, nurses and care staff are nearby to help with walking, getting out of bed, and daily activities. At home, that support is no longer immediately available.
Weakness from bed rest, changes in medication, fatigue, and adjusting to new routines can all affect balance and mobility. Even familiar surroundings can present unexpected hazards during recovery. Falls are one of the leading causes of hospital readmission in older adults, making fall prevention an important part of a safe recovery plan at home.
Medication Management
Medication routines can change after a hospital stay. Discharge instructions may include new prescriptions, adjusted doses, or updated timing for certain medications. Taking time to review these changes with a healthcare provider, pharmacist, or caregiver can help ensure medications are taken safely and as directed. Good medication management is an important part of a safe recovery and can help reduce the risk of complications at home.
Infections
Recovering from an illness, surgery, or other medical treatment can make older adults more vulnerable to infection. Following wound care instructions, taking medications as prescribed, and monitoring for signs of infection, such as redness, swelling, fever, or unusual discharge, are important steps in the recovery process. Early recognition and prompt medical attention can help prevent complications and support a safer recovery at home.
Missed Follow-up Appointments
Follow-up appointments are an important part of recovery after a hospital stay. They allow healthcare providers to monitor progress, answer questions, and address any concerns before they become more serious. Keeping scheduled appointments and understanding next steps can help support a smoother recovery and reduce the risk of complications.
Get Your Information Organized
One of the most important and practical tips is to write everything down as it is presented to you! Don’t rely on memory. Don’t assume the information is somewhere in the paperwork pile. Create a clear and organized notebook or digital document that captures as much as you can before your loved one leaves the hospital. Asking questions is also important. Hospital staff don’t know what you don’t know. Much of what is presented to you and your loved one is not common knowledge. Don’t let embarrassment stop you from asking questions; don’t think “I should know this.”
What Should You Ask The Doctors?
- Diagnosis and procedures: Make sure you understand your loved one’s diagnosis, any treatments they received in the hospital, and what is expected during recovery. Ask the healthcare team to explain any care instructions, activity limitations, warning signs to watch for, and when to seek medical attention.
- Medications: Every medication that needs to be taken, the correct dose, the schedule, and what each one is for. Ask the nurse or pharmacist to go through this with you. Questions to ask include: How much and how often? What is the medication for? What medications cannot be taken in close time proximity to each other?
- Warning signs: What symptoms or changes should the patient and their family look out for? If these symptoms present themselves, should a doctor be called immediately, or should they be taken to the hospital immediately?
- Wound care instructions: If your loved one has a wound, incision, or IV site that requires ongoing care, ask for clear instructions on how to keep the area clean, how often dressings should be changed, and what signs of infection to watch for.
- Activity restrictions: After a medical operation, a temporary lifestyle adjustment may need to occur while the body heals. Figure out what they can and can’t do while they recover. And for how long? For example, a patient leaving the hospital after an operation may not be able to drive for a set amount of time due to the medication they are taking. Depending on the procedure, they may not be able to use any stairs, for example. The doctor might also recommend adding new activities to their daily routine, like short walks or stretching.
- Follow-up appointments: Note all dates, times, and locations of important follow-up or referral appointments. Add them to your calendar before you leave and add any important notes for those appointments. For example, you may be referred to a specialist in a few weeks and be asked to bring specific documentation with you.
Preparing to Leave the Hospital
Going back home to an environment that can support a successful recovery is really important. Before the actual hospital discharge, walk through the individual’s home and look for a few key hazards or barriers:
Fall-proofing the Home
As mentioned earlier, falls are one of the leading causes of hospitalization for older adults in Canada. Risk is highest in the first few weeks after hospital discharge. The body is still recovering, and the muscles may be weaker from all the bed rest. Greater fall risk in the first few weeks can also be due to the sedating effects of pain medication, and changes in blood pressure when standing up, all of which can negatively affect balance.
That is why fall-proofing your home should be done either before or immediately after hospital discharge. Start by removing any tripping hazards from the floor. Loose rugs, extension cords, and clutter are big tripping hazards that are easy to overlook when you’re used to them. Remove them entirely. Make sure to properly take a look at the bathroom; this is the most common fall-risk area in a home. Add support where necessary, like installing grab bars beside the toilet and inside the shower or tub. A raised toilet seat and a shower chair are worth considering, especially in the early weeks when lowering and rising from seated positions puts strain on healing joints and muscles.
Stairways should be well-lit with sturdy handrails on both sides; if stairs are a big concern, temporarily relocating everything you might need to the main floor (a temporary bedroom) entirely removes the risk during the most vulnerable period.
Transitioning to Out-of-hospital Daily Life
We don’t usually think about the level of mobility needed to move through our daily lives. It is only when our mobility level is limited that we really understand how much we rely on it. Every day tasks become increasingly difficult. For example, when mobility is compromised, a space commonly used, like the bedroom, will need more attention. The height of the bed matters. If a bed is too low, getting in and out becomes a strain on the hips, knees, and core. A hospital-style bed rail can provide a secure handhold that reduces the risk of a fall. If a full bed rail isn’t practical, even a sturdy transfer handle that tucks under the mattress or a sturdy side table can help significantly.
Prioritizing nutrition and hydration is equally important and often easy to overlook. Recovery requires a lot from the body. Older adults are already at higher risk of dehydration because feeling thirsty diminishes with age, and some medications compound this. Stock up the kitchen with easy-to-prepare, nutrient-dense foods before discharge day, and make sure water is accessible in every room your loved one spends time in, not just the kitchen.
Figuring Out Communication
Staying well-connected is an important part of a safety strategy. A senior who spends hours alone without a way to reach someone quickly is a senior who is only one fall or medical emergency away from having to revisit the hospital or worse. Before your loved one comes home, make sure there is a working phone or some other means of communication within easy reach at all times and that they have a way of carrying it with them as they move throughout their space.
If possible, a large family group chat or shared calendar can be beneficial and can ease a lot of the pressures that come with caregiving. Rather than your loved one needing to call multiple people with updates, or you fielding calls from siblings asking for information, a single thread keeps everyone informed with minimal effort.
Medical Alert System Can Help After Hospital Discharge
You can’t be with your loved one all day. When they need to be left alone, they need to have a reliable way to call for help should a fall or other medical emergency occur. We all think that if we fall, we’ll just call for help from our phones. However, roughly half of older adults are unable to pick themselves up off the ground after a fall. If the phone is left on a table or counter, there is a good chance that it may be out of reach when needed. That is why having a dedicated medical alert system on your person is important. When a fall or emergency happens, time is of the essence. Issues only intensify the longer somebody is left lying on the floor. A medical alert service is a reliable way to have access to help 24/7.
How do medical alert services work? The user wears a small and discreet help button around the clock, even at night or when bathing. The button is typically worn as a pendant or wristband, and if they fall or feel unwell, they simply press it. A trained response centre associate connects with them, assesses the situation, and contacts the appropriate help: the designated caregiver, another family member, or emergency services if needed.
A medical alert service like those offered by Victoria Lifeline offers not only a reliable and timely response for the wearer, but it also provides support and peace of mind for family members and caregivers. Caregivers who set up medical alert systems for loved ones who are at increased fall risk or living with one or more chronic conditions report significantly lower levels of anxiety. Knowing your loved one can get help at any time, day or night, allows everybody to live with more ease and confidence.
Transitioning to Assisted Living or Long-Term Care
Returning home may not be the best option for every older adult. For some, discharge is the moment when a deeper conversation about long-term living arrangements happens. This can be one of the most emotionally difficult conversations a family will have, but it’s also one of the most important. When is it no longer safe for a parent or loved one to live at home?
Signs That Returning Home Is Not The Best Option
Recovery can sometimes reveal that an older adult needs more support than they did before their hospital stay. If daily tasks, medication management, or health concerns are becoming difficult to manage safely at home, it may be time to explore additional support options. The goal is to ensure the right level of care is in place to promote safety, independence, and peace of mind.
Home Care Services
Home care is often one of the first options families consider when planning for a safe return home after a hospital stay. For many older adults, remaining at home supports independence and allows them to stay connected to familiar surroundings, routines, and community supports.
Home care services can range from a few hours of assistance each week to more intensive daily support, depending on an individual’s needs. Services may be publicly funded through provincial health programs or arranged privately. Home care can be a good option for older adults who are able to live at home safely but would benefit from additional support with daily activities or ongoing care needs.
Retirement Homes & Assisted Living
Retirement homes and assisted living communities can be a good option for older adults who need more support than can be provided at home but do not require 24-hour nursing care. These communities typically offer services such as meals, housekeeping, and help with daily activities, while allowing residents to maintain a level of independence. In addition to practical support, community living can provide opportunities for social connection, recreation, and engagement with others.
In Manitoba, eligible older adults may qualify for financial assistance or subsidized supports to help offset the cost of assisted living services. Understanding what programs are available can help families make informed decisions about care and housing options. Learning about what the province offers can help you figure out what options are best for you and your loved one.
Long-term Care
Government-regulated and subsidized, for seniors with high care needs. Typically, those with advanced dementia, significant mobility limitations, complex medical conditions, or behavioural needs that cannot be safely managed at home or in assisted living. Long-term care facilities offer a level of care that most family caregivers and retirement homes simply cannot: registered nurses on staff around the clock, specialized dementia care units, medical oversight, and direct access to health professionals. Wait lists for long-term care placements can happen, so it’s worth starting the application process early if long-term care may be needed in the near future.
Final Message for Caregivers
If you’re in the middle of navigating the hospital discharge process for an older adult that you love, remember to take a breath. Making your way through this maze can be difficult and stressful. Do not beat yourself up for feeling overwhelmed and not having everything figured out right away. 1 in 4 Canadians are caregivers. That is millions of Canadians who are also navigating the caregiving system. Millions of Canadians are feeling the same stress and anxiety that you are. What’s important is not to get caught up in the sheer number of things there are to do. The most important thing you can do is ask for help and focus on the next step. Ask for help from hospital staff, from your provincial health system, from family, and from community resources. You don’t have to manage this alone.
The goal is to ensure your loved one has the right support in place to recover safely and confidently. By taking time to understand the options available and planning ahead where possible, you are already helping to build a smoother transition from hospital to home.
Disclaimer
This article is meant to be informational in nature and should not replace the advice of a trained healthcare professional.