Post-Hospital Home Care in White Bear Lake and Surrounding Communities

Comfort Keepers provides post-hospital home care for seniors, veterans and adults returning home after hospitalization, surgery, or rehabilitation. Our caregivers help with personal care, meals, mobility, household tasks, transportation, medication reminders, nurse-delegated services and established recovery routines in White Bear Lake, Shoreview, Vadnais Heights, Chisago City and surrounding Minnesota communities.  Our nurses work with the client's medical team to provide Private Duty Nursing services through our Home Health Aides.  

Our services supplement—not replace—the medical care provided by physicians, nurses, physical therapists, occupational therapists and Medicare-certified home health agencies.

What Is Post-Hospital Home Care?

Post-hospital home care, sometimes called hospital-to-home or transitional care, provides practical assistance after someone is discharged from a hospital, rehabilitation center or transitional care facility.

A caregiver can help the client follow established routines, move safely around the home, prepare meals, attend follow-up appointments, and complete everyday activities that may be difficult during recovery.

The purpose is to make the transition home more manageable for the client and family. Post-hospital home care cannot guarantee a specific recovery outcome or prevent every hospital readmission.

Why Can the Transition Home Be Difficult?

Leaving the hospital does not always mean someone is ready to resume every normal activity independently. A senior may return home feeling weak, tired, uncomfortable, or uncertain about new routines.

Common challenges include:

• Reduced strength or endurance
• Difficulty walking or using stairs
• Increased fall risk
• New mobility equipment
• Changes to medications
• Multiple follow-up appointments
• Temporary bathing or dressing limitations
• Dietary instructions
• Physical or occupational therapy exercises
• Confusion about discharge instructions
• Limited family availability
• Household tasks that have accumulated
• Anxiety about managing alone

Medication changes, poor sleep, illness, and an unfamiliar hospital environment can also contribute to temporary confusion- known as delirium. New or worsening confusion should be reported promptly to an appropriate healthcare professional.

Planning for a Safe Return Home

Planning should begin before the client leaves the hospital or rehabilitation facility whenever possible. The hospital’s discharge planner, nurse, or social worker develops the medical discharge plan. Comfort Keepers then creates a non-medical home care plan based on the client’s assessed needs and those instructions.  We prefer to have our Client Care Coordinator attend discharge planning meetings whenever possible.  

Before discharge, families should understand:

• Which medications are new, changed, or discontinued
• When medications should be taken
• Which follow-up appointments are required
• Whether home health nursing or therapy has been ordered
• What activities or movements are restricted
• Whether the person can use stairs
• What equipment is needed at home
• Which symptoms should be reported
• Who to call with medical questions
• Whether someone should remain with the client
• What help will be needed with personal care and meals

The MedlinePlus hospital discharge guide recommends reviewing discharge instructions, medications, equipment needs and follow-up appointments before returning home.  When applicable, our nurse can also assist with medication and other medically necessary procedures like wound care; catheter care; etc.  

Preparing the Home Before Discharge

Simple preparations can make the home easier to navigate during recovery. Depending on recommendations from the medical or therapy team, families may need to:

• Remove loose rugs and other trip hazards
• Improve lighting
• Clear pathways for a walker or wheelchair
• Move frequently used items within easy reach
• Place a sturdy chair in commonly used rooms
• Install approved bathroom safety equipment
• Arrange a first-floor sleeping area
• Obtain a shower chair or portable commode
• Stock the kitchen with appropriate foods
• Fill prescriptions
• Arrange transportation
• Schedule professional caregiver support

A physician, nurse, physical therapist, or occupational therapist should recommend the appropriate medical equipment and home modifications. MedlinePlus offers additional home-preparation guidance.

What Services Can a Post-Hospital Caregiver Provide?

Every client receives a personalized care plan based on their abilities, discharge instructions, home environment, and family support.

Personal Care

• Bathing and showering assistance
• Medication reminders or administration (if ordered)
• Grooming and dressing
• Toileting and incontinence care
• Assistance getting in and out of bed
• Positioning and transfer assistance
• Supervised walking
• Assistance using an authorized mobility device
• Help following established morning and bedtime routines

Meals and Household Support

• Meal planning and preparation
• Grocery shopping
• Hydration and meal reminders
• Dishwashing
• Light housekeeping
• Laundry and linen changes
• Organizing frequently used supplies
• Picking up prescriptions and household necessities

Caregivers follow written dietary and swallowing instructions provided by qualified healthcare professionals.

Transportation and Appointments

• Transportation home after discharge when arranged
• Follow-up medical appointments
• Physical or occupational therapy appointments
• Pharmacy and grocery trips
• Transportation to other approved local destinations

Depending on the care plan, a caregiver may accompany the client into the appointment and help the client keep track of paperwork or questions. Medical decisions remain with the client, authorized representative and healthcare team.

Companionship and Reassurance

Returning home can feel isolating, especially when someone has limited mobility or lives alone. A caregiver can provide:

• Conversation and companionship
• Help maintaining a comfortable routine
• Encouragement to complete approved activities
• Assistance communicating with family
• Support participating in appropriate hobbies
• A reassuring presence during the first days home

Medication Reminders After Discharge

Medication instructions often change during hospitalization. Families should obtain a complete medication list that clearly identifies:

• New medications
• Changed doses or schedules
• Medications that were discontinued
• Possible side effects to report
• The prescribing provider
• The pharmacy to contact with questions

Non-medical caregivers may provide authorized medication reminders and observe whether the client appears to be having difficulty following the established routine. They do not independently prescribe medications, change dosages or guarantee that medications are taken correctly.  Our nurses can work with the medical team to set up medications and have our Home Health Aides administer medications if requested.  

Medication administration or clinical medication management requires a licensed nurse or properly delegated service. Private duty nursing may be assessed and arranged separately when appropriate.

Supporting Physical and Occupational Therapy

Comfort Keepers caregivers do not provide physical or occupational therapy. However, a caregiver may support an established therapy plan by:

• Reminding the client about scheduled exercises
• Encouraging participation
• Helping prepare a clear area
• Retrieving approved equipment
• Providing standby assistance when authorized
• Offering transportation to therapy
• Helping with Range of Motion Exercise when allowed by PT
• Observing and reporting difficulties

Caregivers follow written directions from the physical or occupational therapist. They do not design, change or advance exercises independently.

Working With Home Health and Medical Providers

With the client’s permission or appropriate legal authorization, Comfort Keepers can coordinate relevant services with:

• Physicians
• Hospital discharge planners
• Medicare-certified home health agencies
• Private duty nurses
• Physical and occupational therapists
• Speech-language pathologists
• Rehabilitation facilities
• Hospice or palliative care providers
• Authorized family members

Comfort Keepers caregivers can report observations through established communication channels. Medical professionals remain responsible for diagnosis, clinical assessment, treatment, and medical decisions.

What Is the Difference Between Home Care and Home Health?

Families often use “home care” and “home health” interchangeably, but they are different services.

A client may receive both services at the same time. For example, a home health nurse may visit to provide wound care while a Comfort Keepers caregiver assists with meals, bathing, and household routines between clinical visits.

Medicare states that eligible home health benefits may cover intermittent skilled nursing and therapy. Medicare generally does not cover 24-hour home care or custodial personal care when that is the only care needed. Review Medicare’s home health coverage.

Conditions That May Require Additional Help at Home

Comfort Keepers may support clients returning home following treatment for:

• Congestive heart failure
• Heart attack or other cardiac conditions
• Pneumonia or respiratory illness
• Stroke
• Hip or knee replacement
• Other orthopedic surgery
• Cancer treatment
• Infection
• Fall-related injury
• General weakness or deconditioning
• Exacerbation of a chronic condition

The diagnosis does not determine the care plan by itself. Services are based on the client’s assessed daily needs and directions from qualified healthcare professionals.

Comfort Keepers caregivers do not clinically manage congestive heart failure, heart attacks, pneumonia or other medical conditions. They assist with daily activities and report observed concerns through the established care process.

When Should a Healthcare Provider Be Contacted?

Families should follow the warning signs and contact instructions listed in the client’s discharge paperwork.

Contact the appropriate healthcare provider promptly when the client experiences a concerning change, such as:

• New or increasing confusion
• Worsening weakness
• Difficulty eating or drinking
• Increased pain
• A fall
• New swelling
• A significant change in mobility
• Problems following the medication routine
• A change in behavior or alertness
• A concerning change in a surgical site or skin condition

Call 911 for a medical emergency, including severe breathing difficulty, symptoms of a heart attack or stroke, uncontrolled bleeding, loss of consciousness, or another immediately life-threatening condition.

Temporary, Overnight and 24-Hour Care

Some clients need only a few scheduled shifts after returning home. Others may need overnight or continuous assistance while their strength and mobility improve.

Depending on the assessment and caregiver availability, Comfort Keepers may arrange:

• Short-term transitional care
• Recurring daytime assistance
• Evening care
• Awake overnight care
• Continuous 24-hour shift care
• Respite care for family caregivers

Twenty-four-hour care uses multiple caregivers working rotating shifts so an awake caregiver is scheduled throughout the day and night.

Learn more about our 24-hour home care.

Post-Hospital Care for Veterans

Comfort Keepers provides post-hospital home care for veterans returning home after hospitalization or rehabilitation. Depending on the care plan, services may include personal care, meals, transportation, mobility assistance, household tasks, and companionship.

Eligible veterans may receive authorized homemaker or home health aide services through Department of Veterans Affairs programs. The VA determines:

• Eligibility
• Authorized services
• Approved hours
• Local availability
• Potential copayments

VA authorization does not automatically include every post-hospital service or continuous care. Comfort Keepers can explain its services, but only the VA can determine benefits and authorize VA-funded care.

Learn more about home care services for veterans.

Local Post-Hospital Care Near White Bear Lake and Chisago

Comfort Keepers provides hospital-to-home support throughout the northeast Twin Cities and Chisago County regions.

White Bear Lake Area

The White Bear Lake office serves:

• White Bear Lake
• Shoreview
• Vadnais Heights
• North Oaks
• Hugo
• Forest Lake
• Surrounding communities

White Bear Lake office
1310 Highway 96 E
White Bear Lake, MN 55110
651-789-0317

Chisago County Area

The Chisago City office serves:

• Chisago City
• Lindstrom
• Wyoming
• Stacy
• Forest Lake
• Surrounding Chisago County communities

Chisago City office
11185 Lake Boulevard
Chisago City, MN 55013
651-789-0317

Services depend on the assessment, requested schedule, location and caregiver availability.

Frequently Asked Questions

How soon should post-hospital care be arranged?

Families should begin planning as soon as a discharge date is being discussed. Early planning provides more time to assess the home, understand the discharge instructions and schedule appropriate caregiver support.

Can a caregiver pick someone up from the hospital?

Transportation home may be available when arranged in advance and appropriate for the client’s condition. The hospital must determine that regular transportation is suitable. Medical transportation should be used when required.

Can a caregiver stay overnight after discharge?

Yes. Awake overnight or 24-hour shift care may be available depending on the assessment, requested date, location and caregiver availability.

Can Comfort Keepers manage medications?

Non-medical caregivers provide medication reminders rather than independent clinical medication management. Nursing services may be required for medication administration, pill setup or other clinical tasks.

Can caregivers perform physical therapy exercises?

Caregivers do not provide therapy. They may remind and encourage a client to complete exercises prescribed by a qualified therapist and provide authorized support consistent with the written plan.  When appropriate, they may help with range-of-motion assistance to the client.  

Can Comfort Keepers communicate with the doctor?

With the client’s permission or appropriate legal authorization, the care team can communicate relevant observations through established channels. Comfort Keepers does not replace direct communication between the client and medical providers.

Does Medicare pay for Comfort Keepers post-hospital care?

Medicare may cover qualifying intermittent skilled home health services ordered by a healthcare provider. It generally does not cover ongoing non-medical personal care, homemaker services, or 24-hour care when those are the only services needed. Families should verify coverage directly with Medicare or their health plan.

Can home care prevent another hospitalization?

No provider can guarantee that a client will not return to the hospital. Home care can assist with daily routines, meals, personal care, transportation, and medication reminders while helping families identify and report observed changes.

How do services begin?

A Client Care Coordinator completes an assessment, reviews the client’s non-medical needs, and develops a personalized care plan. With authorization, the team may also review relevant discharge instructions and coordinate with other providers.  In some cases, a Registered Nurse will also review the plan of care and assess the client's needs.  

Schedule a Post-Hospital Care Assessment

A successful return home begins with planning. Comfort Keepers can help your family arrange practical assistance before discharge or add support when recovery at home becomes more difficult than expected.

Call 651-789-0317 to discuss post-hospital home care in White Bear Lake, Shoreview, Vadnais Heights, Chisago City, or a surrounding Minnesota community.

You may also contact Comfort Keepers online to request a complimentary consultation.