Coming home after a hospital stay
Restarting treatment, post-operative monitoring, keeping the link with the ward.
The essentials
- A hospital discharge is organised before leaving: discharge prescription, supplies and first visit agreed in advance.
- The first visit happens as close to discharge as possible, often the same day or the next.
- We take over from the hospital ward on the basis of the discharge report, not on verbal instructions.
- New pain, a wound that changes, or a missing medicine are reasons to call the same day.
Who it is for
People returning home after surgery or a hospital stay.
How we work
- First visit within 24 to 48 hours of discharge when the prescription provides for it.
- We check the discharge prescription, the delivered equipment and your understanding of the treatment.
- Monitoring of vital signs, pain and early warning signs.
- Our hospital background lets us read a discharge report and call the right ward when in doubt.
How a visit unfolds
What happens, in order, when we come to your home.
Reading the discharge file
We read the discharge summary and prescriptions before the first visit, so we arrive already informed.
First visit at home
General state, pain, any surgical scar, current treatments: the starting point is established and written down.
Setting the rhythm
Times and frequency are agreed with you and passed on to every professional involved.
Coordination
GP, pharmacy, physiotherapist, home help: each knows who visits, when, and why.
Reassessment
The plan is reassessed as days pass; what is no longer useful stops, what is missing is reported to the doctor.
Hospital discharge: who does what, on which side
A break in care almost never comes from a missed procedure, but from a box nobody ticked between two organisations.
The hospital ward
Discharge prescription
The ward writes down the care to continue and the date of the first expected visit.
Equipment
The ward states what it supplies and what must be ordered from a pharmacy.
Discharge report
The ward sends its report to the family doctor, who remains in charge of follow-up.
The home-care practice
First contact
We confirm that the sector, the rhythm and the equipment are covered before discharge.
First visit
We come on the agreed date, with the prescription and the discharge report at hand.
Field feedback
We write down what we observe at home and send it to the family doctor.
What helps prepare the visit
Nothing is compulsory: it simply saves time during the visit.
- The hospital discharge summary and the discharge prescriptions.
- The list of treatments actually taken at home.
- Contact details for the GP and the usual pharmacy.
- A clear surface for care materials.
What helps at home
Between visits, these simple habits prevent most urgent calls.
- Keep the discharge prescription, the report and the ward's contact details in one place.
- Clear the space around the bed and the route to the bathroom: that is where most falls happen.
- Have the supplies dispensed by the pharmacy before the first visit, not after.
- Write questions down as they come: they are better asked at the next visit than on the phone at midnight.
When to call us between visits
In a life-threatening emergency, call 15 (or 112) before calling the practice.
- Fever, new pain or pain increasing after the return home.
- A scar that is red, warm, weeping or opening.
- A treatment that cannot be taken, or a box missing at the pharmacy.
- A fall, faintness, or being unable to stand alone when it was possible the day before.
How this care is framed
- Follow-up care is provided on the discharge prescription; the GP then takes over.
- Hospital-to-home handover relies on a written record: we always ask for the discharge summary.
- We report to the prescriber anything that does not match the discharge plan.
The words used here
- PRADO
- The health insurance discharge support programme: an adviser arranges the first community appointments from the hospital before discharge.
- Prescription
- A doctor's written order stating the procedure, frequency and duration. Without it, nursing care cannot be delivered or reimbursed, apart from procedures allowed in direct access.
- Handover notes
- The written record of a visit: what was done, what was observed, what must be watched. The shared memory of the care episode.
- Home hospitalisation (HAD)
- A structure delivering hospital-level care at the patient's home, with its own medical coordination.
Common questions about this care
When should I call after a hospital discharge?
Do you work with the hospital?
What if the equipment is not delivered?
Should we wait for discharge before contacting you?
What if the discharge prescription is incomplete?
Can you take over from another practice?
Official sources
What we state about the framework of care comes from these public texts, consulted on the date shown.
Related care
These forms of care often go together.
Where we provide this care
Towns in our sector where this care is most frequent.
This care is provided on medical prescription. To find out whether we can visit you, call 04 04 38 04 38.