Going home is the goal of every hospital stay. It is also when many things can go wrong. You may be weaker than you expected, juggling new prescriptions and trying to remember instructions you got on a busy discharge day. Post-hospital home health care in Tampa helps close that gap: a nurse and therapists come to you while you recover, so problems are caught early instead of turning into a trip back to the emergency room. This guide covers what to do before you leave, what to watch for once you are home, and how the same approach applies after rehab or pneumonia.
Before you leave: make discharge planning work for you
Every hospital has discharge planners or case managers. Their job is to plan a safe return home, and they work best when you ask questions. Before you leave, make sure you can answer these:
- What was my main diagnosis, and what caused this stay?
- Which medicines are new, which changed and which should I stop?
- What warning signs should make me call the doctor, and which mean call 911?
- When is my follow-up appointment, and with whom?
- What can I eat, and what activity limits do I have?
- Will I need equipment like a walker, shower chair or oxygen, and who delivers it?
- Is home health being ordered, and for which services?
Ask the nurse to explain anything confusing, then repeat it back in your own words. If Spanish is your preferred language, ask for an interpreter and written instructions in Spanish.
One more question worth asking: “Was I admitted as an inpatient, or kept under observation?” Observation is billed differently. It can affect whether Medicare covers a skilled nursing facility stay afterward.
You have a choice of home health agency
If your doctor orders home health care, the hospital should give you a list of Medicare-certified agencies that serve your area and respect your choice. You do not have to accept whichever agency is suggested first. Medicare Advantage plans may limit you to their network.
Tell the discharge planner which agency you want, or have a family member call the agency directly so the referral is ready before discharge day. Making Memories Home Health coordinates with discharge planners and doctors at hospitals such as Tampa General Hospital, St. Joseph’s Hospital and Lakeland Regional Health. Our guide on how to choose a home health care agency explains what to compare.
Your first day home
Keep the first day simple:
- Fill new prescriptions on the way home, or arrange delivery.
- Set up a bed, chair and bathroom path with nothing to trip over.
- Have easy food and water within reach.
- Put discharge papers and every medication bottle in one spot for the nurse.
- Make sure someone can stay with you, or check in, for the first night if you can.
Medication reconciliation: the most important first step
Medication reconciliation means comparing the hospital’s discharge list with every medicine actually in your home. It sounds simple, but this is where many mistakes start. Common problems include:
- The same medicine under a brand name and a generic name, taken twice
- An old dose still in the cabinet after the hospital changed it
- A medicine the hospital stopped that is still being taken out of habit
- A new prescription that was never filled
- Over-the-counter pills or supplements that interact with new prescriptions
- Confusion about timing, such as with food or at bedtime
At the first visit, your home health nurse goes through every bottle, including vitamins, inhalers, eye drops and creams. The nurse reports any mismatch to your doctor, teaches you what each medicine is for, and helps you set up a system you can follow, such as a pill organizer and a written schedule. Learn more on our medication management page.
Two habits help: use one pharmacy when you can, and keep an updated list on the refrigerator for emergencies.
Your first 30 days at home
Recovery is not a straight line, and the first month is when you need the most support. A typical pattern looks like this:
Week 1. The start-of-care visit, medication reconciliation and a home safety check. Therapists come for their first evaluations. You learn your warning signs and get to your follow-up appointment.
Weeks 2 and 3. Therapy builds strength and endurance. The nurse watches trends in blood pressure, weight, blood sugar, breathing or wound healing, and reports changes to your doctor. Family caregivers learn what to do between visits.
Week 4 and beyond. You take over more of your own care. Visits often taper. The team starts planning your discharge from home health, including a home exercise program and next steps such as outpatient therapy.
Warning signs that could lead back to the hospital
Many readmissions start with a small change that grows over a few days. Call your doctor or our office during business hours if you notice:
- A fever, chills or a cough that is getting worse
- New or worse shortness of breath with activity, or needing more pillows to sleep
- Swelling in the legs or sudden weight gain (ask your doctor how much gain to report)
- Redness, warmth, swelling, drainage or odor at a wound or incision
- New confusion, extreme sleepiness or unusual weakness
- Not eating or drinking, vomiting, or being unable to keep medicines down
- Dizziness, a fall or a near-fall
- Blood sugar readings outside the range your doctor gave you
- Pain that your medicines are not controlling
Call 911 right away for chest pain or pressure, severe trouble breathing, signs of stroke (face drooping, arm weakness, trouble speaking), fainting, heavy bleeding, or lips or fingertips turning blue.
If you live with heart failure, COPD or diabetes, our guides to heart failure, COPD and diabetes care at home go deeper on the signs specific to each.
Coming home from a skilled nursing facility or rehab
A stay in a skilled nursing facility or inpatient rehab can rebuild a lot of strength, but home is a different test: no call button, no grab bars, maybe steps at the front door. The same rules apply as after a hospital stay. Ask the facility to send your medication list and orders to your home health agency, and arrange the referral before discharge day, not after. Our guide to going home after a skilled nursing facility covers that move step by step, including bringing a loved one home after a long facility stay. Home health visits are part-time, so plan who covers the rest of the day and night. Our comparison of home health care and assisted living can help you weigh the options.
Recovering from pneumonia at home
Pneumonia often leaves people tired and short of breath for weeks after the infection clears, especially older adults and those with lung or heart disease. Recovery at home usually involves:
- Finishing all antibiotics exactly as prescribed, even if you feel better
- Breathing exercises, or an incentive spirometer if one was prescribed
- Drinking enough fluids, which matters even more in Florida heat
- Balancing rest with short, frequent walks to rebuild endurance
- Asking your doctor which vaccines, such as pneumonia and flu shots, are right for you
Your nurse checks your lungs, temperature, oxygen level and medicines. A physical therapist rebuilds endurance safely. An occupational therapist teaches energy-saving ways to bathe and dress. Call your doctor if fever returns, your cough or breathing gets worse, or you become confused. Call 911 for severe breathing trouble or chest pain.
How Making Memories Home Health can help
Making Memories Home Health Inc is a Medicare-certified, Joint Commission accredited home health agency based in Tampa. After a hospital or rehab stay, we provide skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work and home health aide visits as part of your care. Our team speaks English and Spanish.
We serve patients coming home across Hillsborough, Polk and Manatee counties. Doctors and discharge planners can send referrals through our referrals page. Families can call us at (813) 931-0015. We verify your benefits and explain any costs before care starts.
Frequently asked questions
When does home health start after I leave the hospital?
The first visit is scheduled once the agency has your referral and doctor's order. The best way to avoid a gap is to choose your agency before discharge and make sure the referral is sent ahead of your discharge day. Ask the agency when they plan to see you.
Do I need to go to rehab before I can get home health care?
No. Many people go straight from the hospital to home with home health. Others need a short stay in a skilled nursing facility first and start home health when they leave. Your medical team will recommend what is safest.
Can I get home health care if I was in the hospital under observation?
Yes. Medicare home health does not require an inpatient hospital stay. Observation status mainly matters for whether Medicare will cover a skilled nursing facility stay afterward.
What does a home health nurse check on the first visit after discharge?
The nurse reviews your discharge instructions, compares every medicine in the house with your new list, checks vital signs and any wounds, and looks for safety hazards. You also go over warning signs and who to call.