Hospital-to-Home Recovery Support

Door-through-Door Recovery Support

The Hospital-to-Home (Door-through-Door) Recovery Support program provides critical support to seniors who are, or have recently been, hospitalized. The program helps to ensure appropriate care and resources are available post-discharge -- enabling the greatest opportunity for a full, safe recovery.

When a patient is discharged from a hospital stay, their focus needs to be on healing, without the worry of figuring out how to overcome all the other challenges an illness, surgery, or accident might initiate.

The Door-through-Door program helps ensure that medical care plans and social support systems are in place so that clients can safely return home and focus on that healing. Our program also aims to help break the cycle of repeated hospitalizations by ensuring that needed resources and support are available before, during, and after a hospitalization. Whether that means having access to a walker or bedside commode, having a home caregiver right away, having transportation to a doctor or physical therapy appointment, or having prepared food at home during recovery -- we help to make sure that critical needs are met so that stress is reduced, and re-admission risk is minimized.

Our Door-through-Door Coordinator will work directly with the senior and/or their family members, as well as the hospital discharge planners and case managers, to understand each unique health and home situation, and to identify risks and needs. By educating family members about their rights, and what post-discharge services they may need to ask about, we are often able to mitigate potential challenges before they occur. In order to prevent additional injuries, the Coordinator will often schedule a home visit to look for, and address, fall risks or other safety risks in the home. Our Coordinator has connections with over 2,000 local resources that they can call upon to help with most any situation, and we have connections with all of the local Fallbrook-area skilled nursing and rehabilitation facilities, board and care, and assisted living facilities, if any of them should be needed.  Our relationships with local-area hospitals and other organizations help us to work together for the best possible health outcomes for our seniors.

Our Door-through-Door Coordinator also works closely with the North County Fire Protection District and other first responder organizations to ensure that we engage as quickly as possible with a potential hospital-to-home client. If the senior is taken to a nearby hospital, or if there are needs identified in a senior’s home care, the Fire Department personnel will provide a referral, upon consent, to our program. Once we receive that referral, we reach out to the hospital to get an update on the patient’s status, we speak to the patient or their family, and we begin our work to connect the senior with the appropriate resources that they may need.  Sometimes, these referrals come from caring neighbors or friends. During this fragile time after a hospitalization, we are here to help and are only a phone call away.


I am so proud to be a part of the Hospital-to-Home Transitions program. At every stage of the discharge and healing process, measures are being put in place to mitigate the risk of my client being re-admitted to the hospital. Whether I am interfacing with a client’s family member, a hospital discharge planner, the admissions coordinator at a rehab facility, or a neighbor who’s going to make some prepared meals, I work hard to ensure that my client has the resources and help to be safe, comfortable, and as stress-free as possible so that they can heal.

Elisha W.

Hospital-to-Home Coordinator

Need A Ride?

Door-to-door rides in our comfortable Care Vans
Referrals & Support

Need Help?

Referrals, resources, and support advocacy
Adult Day Care Center

Need Adult Caregiving Or Respite?

Trusted, daytime, adult caregiving
Senior Education

Need To Know How And What?

Technology classes and informational workshops