What Discharge Planners Should Know About Private Duty Home Care

You've done everything right.

The patient is medically stable. The discharge paperwork is complete. You've arranged home health visits, reviewed medications, and provided education about warning signs.

And yet, within 30 days, they're back.

Hospital readmissions remain stubbornly persistent, especially among older adults. And while the reasons are complex, one factor comes up repeatedly: the gap between what patients need at home and what skilled home health actually provides.

This is where private duty home care makes a difference — and why discharge planners should understand what it offers.

The Gap Skilled Home Health Doesn't Fill

Medicare-certified home health provides essential services: nursing visits, physical therapy, wound care, medication management. But it has inherent limitations:

Intermittent, Not Continuous Home health visits typically last 30-60 minutes, a few times per week. That leaves the vast majority of hours uncovered — hours when falls happen, medications are missed, and meals don't get made.

Skilled, Not Custodial Home health addresses medical needs but not daily living needs. There's no one to help with bathing, prepare meals, provide supervision, or ensure the patient is actually following discharge instructions.

Time-Limited Home health is designed for recovery and stabilization. Once patients are "stable," services end — whether or not they can actually manage independently.

Requires Medical Necessity Patients who don't qualify for skilled care have no Medicare-funded home support option at all.

These limitations create the conditions for readmission: patients return home, struggle without adequate support, and end up back in the hospital.

What Private Duty Home Care Provides

Private duty (non-medical) home care fills the gaps that skilled home health cannot:

Extended Hours of Support Care is available for as many hours as needed — from a few hours daily to 24/7 coverage. Someone is actually present during the vulnerable hours after discharge.

Daily Living Assistance Caregivers help with bathing, dressing, toileting, mobility, meal preparation, medication reminders, and all the activities that determine whether someone can actually function at home.

Supervision and Monitoring Especially for patients with cognitive impairment, having a trained caregiver present prevents the behaviors that lead to readmission: wandering, falls, medication errors, failure to recognize warning signs.

Continuity and Consistency The same caregiver coming day after day knows the patient, notices changes, and can alert family or providers when something seems wrong.

Flexibility Care can begin immediately upon discharge — even the same day. Hours can be adjusted as the patient improves or as needs change.

How Private Duty Care Reduces Readmissions

The connection between adequate home support and readmission prevention is straightforward:

Patients Actually Follow Discharge Instructions A caregiver reinforces medication schedules, dietary restrictions, activity limitations, and follow-up appointments. Instructions don't get lost in the confusion of coming home.

Falls Are Prevented The presence of a caregiver during transfers, bathing, and ambulation dramatically reduces fall risk during the vulnerable post-discharge period.

Warning Signs Are Caught Early A caregiver who sees the patient daily notices when something changes — increased confusion, swelling, shortness of breath, decreased appetite. Early detection means early intervention.

Nutritional Needs Are Met Patients who can't shop or cook for themselves often don't eat well. A caregiver ensures proper nutrition, which directly supports recovery.

Medication Errors Are Reduced While caregivers don't administer medications, they provide reminders and can help organize pill boxes, reducing the missed doses and double-doses that lead to complications.

When to Consider Private Duty Referrals

Private duty home care is particularly valuable for patients who:

1. Live alone without reliable family support
2. Have cognitive impairment (dementia, delirium)
3. Have significant fall risk
4. Are being discharged with complex medication regimens
5. Have limited functional ability (difficulty with ADLs)
6. Don't qualify for home health or have exhausted home health benefits
7. Have family caregivers who are overwhelmed or unavailable during key hours

What Families Need to Know

When discussing private duty home care with families, key points to communicate:

It's Not Covered by Medicare This is often a surprise. Help families understand that Medicare doesn't cover custodial care, but that other payment options exist (private pay, long-term care insurance, veterans benefits).

It Complements Home Health Private duty care doesn't replace skilled home health — it works alongside it, filling the hours between nursing visits.

It Can Be Short-Term or Long-Term Some families need intensive support for the first few weeks post-discharge; others need ongoing care. Both options are available.

Quality Varies Encourage families to ask questions about caregiver training, supervision, and background checks. Not all agencies are equal.

Partnering for Better Transitions

Discharge planners are the critical link between hospital and home. Understanding the full range of options — including private duty home care — allows you to help families build truly adequate support systems.

The goal is the same: patients who thrive at home rather than returning to your unit.

If you'd like to discuss how private duty home care can support your patients' transitions, we welcome the conversation.

Contact Geriatric Care Solutions: Phone: 1-888-896-8275 Email: ask@gcaresolution.com