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Care transitions · JourneyWell field guide
Preparing for Discharge Home After a Major Hospitalization
Turn a discharge plan into a realistic home plan before leaving the hospital.
General educational information · Updated September 2026
The real challenge
A discharge can be medically appropriate while the home, caregivers, equipment, and follow-up plan are not yet workable.
What may be happening
- Instructions may come from several disciplines at different times.
- Families may overestimate what one caregiver can safely manage.
- Equipment, medications, transport, or follow-up may not be coordinated.
What families can do now
- Ask for a written medication list showing what changed.
- Have the person doing hands-on care demonstrate required tasks before discharge.
- Confirm equipment delivery, transportation, and first follow-up appointments.
- Name the gaps plainly before agreeing the plan is workable.
Questions to bring to clinicians
- What changes should prompt a same-day call or emergency care?
- Who do we contact tonight or over the weekend?
- What home health, therapy, or equipment is ordered, and when will it arrive?
When JourneyWell support can help
JourneyWell can help review the practical plan, map caregiver capacity, and organize unanswered questions before and after discharge.
Urgent and emergency note
Urgent symptoms belong with the treating clinical team; emergencies require 911 or local emergency services.