Why the first weeks at home matter
Leaving the hospital is a handoff. The hospital team steps back, and the people who will look after you next may not yet know what happened. Medications have changed. You are weaker than usual and still recovering.
Transitional care at home after a hospital stay in St. Louis is meant to close that gap. A primary care clinician reviews what happened in the hospital, checks how you are doing at home and takes over the plan. Clinicians use the term transitional care for this follow-up in the weeks after discharge.
What a transitional care visit covers
The treating clinician decides what the visit includes. In general it covers:
- The discharge summary: why you were admitted, what was done and what is still pending
- Every medication, comparing the discharge list with what is in the home
- Symptoms since coming home, including pain, appetite, sleep, bowels and mood
- Test results that were not ready at discharge, and follow-up tests that are due
- Specialist appointments, and which ones matter most
- Equipment, home health, therapy and help at home
Many practices also call soon after discharge to check in before the visit. Your discharge papers usually say when the hospital wants you seen.
Medications after discharge
Medication mix-ups are a common problem after a hospital stay. A drug may have been stopped, started or changed in dose, while the old bottles are still in the cabinet.
Bring every bottle to the first follow-up visit, or set them out on a table for a home visit. A medication review compares the lists and sends questions to the prescriber. Until then, follow the discharge instructions and call the hospital unit, your pharmacist or your physician with any doubts.
When you come home with a wound
A surgical incision, a pressure injury that developed during the stay, or a leg or foot ulcer that led to the admission all need a plan that continues at home. Discharge orders for dressings are written for the first days. After that, someone has to look at the wound again.
Gateway arranges wound follow-up after hospital discharge with Gateway clinicians and keeps the primary care clinician informed. That link matters because healing depends on things primary care manages, including blood sugar, fluid balance, nutrition and medications. If home health is also involved, we coordinate with the home health agency so the nurse and the wound clinician work from the same orders.
Coming home from rehab or skilled nursing
Discharge from a rehabilitation center or skilled nursing facility is a second handoff. Therapy ends or moves to the home. The facility’s physician is no longer in charge. Supplies that staff used to handle now have to be ordered.
Before you leave, ask the facility for a discharge summary, a current medication list and the most recent wound measurements. Our page on continuity of care explains how we keep track of those details as someone moves between settings.
What Gateway arranges
- We take the request from you, a family member, or the hospital or facility discharge team.
- We ask who your primary care physician is and let that practice know you are home. If you do not have one, we help with finding a primary care clinician.
- We collect the discharge paperwork and medication list for the treating clinician.
- We arrange primary care follow-up, wound care or both in your home or facility, where a Gateway clinician is available.
- We coordinate supply orders, transportation arrangements when needed, and updates among the care team.
The treating clinician makes every clinical decision.
Warning signs after discharge
Call your clinician promptly for:
- Fever, chills, or a wound with spreading redness, new drainage or an incision that is opening
- Pain that is getting worse
- Not eating or drinking, or repeated vomiting
- New swelling in the legs or rapid weight gain
- Dizziness, a fall or new confusion
- Any medication you cannot get or do not understand
Call 911 for chest pain, trouble breathing, fainting, heavy bleeding, sudden weakness or numbness on one side, trouble speaking, or a suddenly painful, swollen leg with shortness of breath. Gateway is not an emergency service.
How to start
Call 314-325-0126 as soon as a discharge date is known, or earlier. You can also send the request care form with a name and phone number only, and we will call back.
Families can use the guide to the first two weeks after the hospital to plan the days ahead, and the family discharge checklist when a wound is involved.
Common questions
How soon after discharge should I see a primary care clinician?
Your discharge instructions usually give a timeframe. Ask the hospital team for a specific date before you leave. Gateway cannot promise visit timing, since availability depends on your location and care setting, but calling early leaves the most room to arrange follow-up.
Can follow-up happen at home instead of at an office?
Often it can. Gateway clinicians see patients in private homes, assisted living and other settings, which helps when someone is weak, in pain or unable to drive. Whether a home visit is available depends on where you live and on the treating practice.
What should I have ready for the first visit after the hospital?
Gather the discharge summary, the discharge medication list, every pill bottle in the home, any wound care instructions and a list of upcoming appointments. Write down your questions and any symptoms since coming home. If a family member helps with care, ask them to be there.
Does my regular doctor find out that I was in the hospital?
Not always. Hospitals send records to the physician listed in your chart, but that listing can be out of date. Tell the hospital who your primary care physician is, and call the office yourself once you are home. When Gateway is involved, we contact the practice as well.
Related pages
General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.