Planning for Next Steps at Home

Due in part to the Affordable Care Act – as we have mentioned previously in our blog – hospitals will be vulnerable to Medicare reimbursement reductions due to patient re-admissions within 30 days of discharge.

To provide a viable and affordable solution for patients who are not able — either through their own efforts or those of their family caregivers — to follow their discharge plan or manage their care following hospitalization, Home Care Partners will supervise and support patient safety and comfort in their home. Our services begin when the patient first returns home, and we focus on solving such issues as home safety and fall prevention; changes in medication and care plan administration; and greater compliance with physician follow-up visits.

Our approach is to “frontload” initial care planning immediately upon the patient’s discharge. We may meet the patient at the hospital with care staff and accompany/escort them safely home. Or, meet at home upon arrival from hospital.

Home care services will focus on:

• Assisting the patient in “comfort measures,” such as dressing and bathing.

• Making “safety adjustments” in the home, such as removing clutter in hallways and placing such frequently used devices as phones and remotes within easy reach.

• Making sure new prescriptions have been picked up.

• Seeing that items in the refrigerator are fresh, groceries have been picked up, and light meals prepared.

• Assisting the patient in contacting their primary care physician to schedule follow-up visits, if necessary.

 Within 7 – 10 days, our goals subtly shift to:

• Assist the patient in dressing and preparation for physician appointment.

• Provide transportation to and from the doctor, if necessary. We will accompany our elderly clients to their meeting, and join discussions with their doctor. All parties can review initial discharge plans and assess needs.

• Offer additional private, personalized care in their home.


– John D. Miller is the owner of Home Care Partners, LLC, a Massachusetts business providing private duty, personalized in-home assistance and companion care services to those needing help in daily activities and household functions. He can be reached at: (781) 378-2164; email:; or online at: