Palliative Care · Post-Acute Transitions
The first week home is the one that decides the next month.
Discharge from a hospital or rehab facility is the highest-risk moment in a patient’s care. A physician at the bedside in those first days catches what a phone call cannot.
What we do in the first days home
- Reconcile discharge medications with what’s actually on the counter.
- Assess the home for safety — falls, oxygen, mobility, sleep setup.
- Speak directly with the hospital team when questions remain.
- Watch for the early signs of decompensation — often subtle, always time-sensitive.
Why it prevents readmission
- Symptoms are treated before they escalate to a 911 call.
- Families get one clinician who knows the story — not a rotating cast.
- Care plans are adjusted to the patient at home, not the patient on a hospital floor.
- Follow-up specialist appointments are coordinated, not just recommended.
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