Hospital to Home Program

When you are discharged from the hospital and you return home, our Hospital to Home program helps to ensure that your recovery is as successful as possible. Here's what you can expect:

 Meet your Hospital to Home social worker

Your Hospital to Home social worker will visit you in your hospital room to discuss the program and to answer any questions. The program includes post-discharge phone calls and a home visit by your social worker to check on the progress of your care plan and recuperation. Please feel free to include any family members who will be at home with you.


 Discuss your wellness plan with your discharge team

Your discharge team includes your social worker, a pharmacist, case manager, and nurse. Prior to discharge, your team will discuss important discharge instructions, including what dosages and frequency of medications to take, activity restrictions, and what foods to eat. Your case manager and nurse will help you understand your diagnosis and any symptoms that will need to be monitored.

 Schedule your visit

 Prior to discharge, your social worker will schedule a convenient time to visit you at your home within four days of discharge.

 Your social worker will call you at home

 Twenty-four to forty-eight hours after your discharge, your social worker will call you to follow up on your care plan and to confirm your home visit.

 Your social worker visit

During your home visit, your social worker will discuss your discharge instructions and confirm your follow-up appointment with your doctor. At this time, you will be able to ask any questions about your discharge instructions, medications, or other concerns relevant to your wellness. Your social worker will also check to be sure that you have any equipment that you were prescribed at discharge. Before he/she leaves, your social worker will be happy to provide you with referrals to community resources that may be of help to your recovery. 

 Talk by phone a week later

About one week after your home visit, your social worker will call to see how you are progressing and to answer any additional questions.

 Your health and well-being are important to us. Let’s work together to make this transition as smooth as possible. For more information call 951.688.2211 ext. 4016

 Hospital to Home Transitions is offered at no cost to our patients.