Post-Discharge Home Care Guide: The First 90 Days

Discharge does not mean treatment is over; the critical period starts now. Research shows about one in five patients over 65 is readmitted within 30 days — and a large share of those readmissions are preventable, caused by medication non-adherence, lack of follow-up and missing home care.

The first 48 hours: set the routine

• Digitize the discharge summary and medication list; clarify each medication's time, dose and with/without food.
• Set up medication reminders on the phone — one missed dose becomes a missed week.
• Check that devices like the blood pressure monitor and glucometer work and are used correctly.
• Note the follow-up appointment date and plan transport now.

Daily routine: measure, record, share

Regular measurement is the strongest tool of the post-discharge period. Blood pressure, pulse and (if needed) glucose should be measured at the same times every day and recorded. In the WellFamily app, a family member or caregiver enters the measurement on the phone; with consent, the patient's physician sees the same data instantly, and when values worsen the app automatically alerts the physician — that is exactly how an outpatient check replaces an ER visit.

• Measure at the same time of day, at rest.
• Keep a daily note: appetite, sleep, mood — small changes are early signals.
• Mark medication intake; your adherence rate is your physician's most valuable data.

Prepare the home

• Remove fall risks such as rug edges, cables and thresholds; add a night light.
• Install a grab bar and non-slip mat in the bathroom.
• Move frequently used items to waist–eye level; reduce stair use.

You are not alone: caregiver and physician support

If family cannot be there every day, a verified caregiver can take over the medication routine, measurements and daily rhythm. If your hospital works with WellFamily, your physician can keep following you through the app after discharge; you can find partner hospitals and member discounts on the Partner Hospitals page of our website.