Post-Hospital and Post-Surgery Care

The gap nobody plans for

Discharge planning covers the medical part — medications, follow-up appointments, sometimes a visiting nurse for a limited time. What it does not cover is the ordinary part: who helps them to the bathroom at three in the morning, who cooks, who notices that they have not stood up since yesterday.

That gap is where readmissions come from. Not failed surgeries. Falls, missed medications, dehydration and infections that nobody caught in time.

What we cover in those weeks

• Help getting up, moving and using the bathroom safely — the highest-risk activity in the house
• Medication reminders on the new post-discharge schedule, which is usually different and confusing
• Meals and fluids, because appetite after a hospital stay is poor and dehydration comes fast
• Transportation to follow-up appointments, the ones people skip when getting there is hard
• Watching for warning signs — new confusion, a wound that looks wrong, swelling, a fever
• Encouraging prescribed exercises so recovery does not stall

Call before the discharge, not after

Families almost always call us two days after their father came home, once it is obvious he cannot manage. Arrange care while the discharge date is still on the calendar and the first night home has someone in it.

If a case manager or discharge planner is involved, put us in touch with them directly — we work with hospital and rehab discharge teams across the Lehigh Valley and the Poconos.

How long it lasts

Some families need three or four weeks and then stop. Others discover during those weeks that the help was overdue anyway and continue at a lower level. Both are normal.

Where we provide this

Allentown, Bethlehem, Easton, Stroudsburg, East Stroudsburg and across Lehigh, Monroe and Northampton counties.

Paying for it

Community HealthChoices, Act 150, the OBRA Waiver, VA Community Care, long-term care insurance, and private pay. Read the full guide →