Post-Surgical Recovery
Skilled nursing and rehabilitation after joint replacement, heart, abdominal, or spine surgery, covering incision care, pain control, and safe mobility.
Learn moreRecovery & Condition Programs
Hospital Discharge Care
Coming home from the hospital is a huge relief, but those first few days can also feel overwhelming. Our transitional care team meets you at home right away to sort through your discharge paperwork, organize your medications, and help you settle in safely.
- Provided by
- Registered nurses and your Royal care team
- Ordered by
- Your physician or allowed practitioner
- Availability
- Mon to Fri, 9:00 AM to 5:30 PM, with a nurse on call after hours
- Where
- In your home, across 4 Southern California counties
Overview
About Hospital Discharge Care
A lot changes during a hospital stay. You often come home with a stack of instructions, new prescriptions, different doses of old medications, and follow-up appointments to schedule. One of our registered nurses visits shortly after you walk through the door to sit down with you, compare your pill bottles against your discharge list, and make sure nothing is missing.
We stay in close touch with your hospital discharge planner and your primary doctor so everyone is on the same page. If your recovery also calls for physical therapy, occupational therapy, or a home health aide to help with showering, we coordinate all of it under one plan.
What's included
- Prompt start-of-care nursing visit right after you return home
- Side-by-side medication review comparing what is in your cabinet to your hospital discharge list
- Walking through your discharge instructions, diet, and activity guidelines in plain English
- Checking your vital signs, surgical sites, and overall comfort
- A practical home safety walkthrough and medical equipment check
- Helping coordinate follow-up doctor visits and lab work
- Clear guidance on what symptoms to watch for and when to call us
- Bringing in physical therapy, occupational therapy, or home health aides when ordered
Who it helps
- Anyone returning home after a stay in the hospital or a skilled nursing facility
- Patients juggling new or changed medication schedules after discharge
- People recovering from heart failure, pneumonia, COPD flare-ups, or serious infections
- Families who want an experienced nurse checking in during the first weeks home
What to expect
Your care, step by step.
Step 1: Before discharge
Your hospital case manager or doctor sends us your referral, or your family calls our Van Nuys office directly.
Step 2: First visit home
A registered nurse visits your home, checks your vitals, organizes your medications, and answers your questions.
Step 3: Coordinated plan
Together with your physician, we set up your nursing, therapy, and aide visit schedule.
Step 4: Steady recovery
We visit regularly, coach your family, and update your doctor until you are back on your feet.
Staying safe
When to call us or your doctor
Our office is open Monday to Friday, 9:00 AM to 5:30 PM. A registered nurse is always on call by phone after office hours, on weekends, and on holidays.
Call us or your physician if you notice:
- Shortness of breath, new swelling in your legs, or worsening pain
- A fever, chills, or redness around an incision or IV site
- New confusion, dizziness, or unusual grogginess
- Confusion about which pills to take or when to take them
For chest pain, trouble breathing, signs of stroke, severe bleeding or any emergency, call 911.
How soon after I get home will the first visit happen?
We aim to make your first home health visit within 48 hours of your referral or your return home, or on the specific start date ordered by your doctor. We reach out as soon as we receive your referral to schedule a time that works for you.
Can the hospital refer me directly to Royal?
Yes. Hospital discharge planners and case managers send referrals to our intake team every day. You also have the right to choose your own home health agency. Just let your discharge planner know you would like Royal Home Health Care.
What if I need help with bathing and getting dressed at first?
When you are receiving skilled nursing or therapy under a home health plan, we can include a certified home health aide to help with showering, grooming, and dressing while you regain your strength.
Related services
Ask us about Hospital Discharge Care.
Call us with questions, to make a referral, or to check whether you qualify. A real person answers during office hours, and a registered nurse is on call after hours.