Helping patients transition safely from hospital to home takes a team.
For many, knowing when to recommend home healthcare can be the key to a smooth recovery and better long-term outcomes. This quick guide outlines when home health is appropriate, what types of patients benefit most, and how referrals typically work.

Who Benefits from Home Healthcare?

Home healthcare is ideal for patients who:

• Are homebound or experience difficulty leaving the home without assistance
• Require skilled nursing, therapy, or medical social work at home
• Have recently been discharged from the hospital or rehab facility
• Are managing chronic conditions that need close monitoring
• Need short-term recovery support after surgery, injury, or illness

Common Referral Scenarios

1. Post-Surgical Recovery
   Patients who need wound care, medication management, physical therapy, or monitoring for complications after a procedure.
2. Fall Risk & Mobility Issues
   Seniors or recovering patients who are at risk of falls but do not require 24/7 inpatient care.
3. Medication Management Support
   Patients with complex regimens, memory issues, or new prescriptions who are at risk for medication errors.
4. Chronic Disease Management
   Patients with heart failure, COPD, diabetes, or hypertension who benefit from nursing oversight and education.
5. Neurological Conditions
   Those recovering from a stroke, or managing Parkinson’s or MS, who may need therapy, speech support, or daily assistance.
6. Palliative & End-of-Life Support
   Patients who need comfort-focused care at home but are not yet appropriate for hospice.

What Home Healthcare Includes

Home healthcare services vary based on the care plan but may include:

• Skilled nursing for wound care, injections, and chronic condition monitoring
• Physical, occupational, or speech therapy to restore function and independence
• Medical social work to help navigate psychosocial needs and community resources
• Home health aides to assist with daily activities and ensure patient safety
• Ongoing care coordination with the patient’s primary physician or specialists

Why Referrals Matter

Timely home healthcare referrals:

• Reduce hospital readmissions
• Support patient and family confidence at home
• Improve clinical outcomes through early intervention
• Extend your care team’s impact beyond the facility

Let’s Work Together

Home healthcare helps bridge the gap between hospital and home. When referred at the right time, it can reduce readmissions, improve outcomes, and support the goals of the entire care team.

Need help determining if a patient qualifies or what services are available in your area? Our team is here to support you with quick evaluations, clear communication, and a streamlined referral process. Contact our team directly for guidance.