Transitional care / 72 hours
Transitional Care After a Hospital Stay
Transitional care is everyday help at home in the weeks after a hospital stay: meals, getting washed and dressed, reminders, rides to follow-up visits, and someone nearby while strength comes back.
- Discharge day
- The first 72 hours
- The first weeks
- Steady again
Nobody should have to manage the first weeks home alone.
Endurance Home Care, a home care agency registered in Connecticut as Homemaker Companion Agency HCA.0002450, provides transitional care after a hospital stay, with help at home by the hour, overnight, live-in or around the clock, and Endurance Homebound, our plan for the first 72 hours after discharge.
Transitional care is one of four ways Endurance schedules care, alongside 24/7 care with live-ins, hourly care, and care inside a facility. If the doctor has ordered nursing or therapy at home, those visits come from a home health agency, and our caregiver helps with the day around them: meals, getting washed and dressed, moving safely, reminders and company. In Connecticut, our separate company, Endurance Home Health, provides skilled nursing, home health aides and physical therapy.
Knowing which is which tells you who to call for what. A nurse may come to check on a wound, but nobody is sent to make lunch, clear the way to the bathroom or drive to the follow-up appointment. That second list is what we help with.
Why the first week home gets extra attention.
13.9
Thirty day all cause hospital readmissions per 100 index admissions in the United States, holding flat from 2016 to 2020. AHRQ HCUP Statistical Brief, 2016 to 2020 data
36.1%
Share of all thirty day readmissions that happen within seven days of discharge. AHRQ HCUP Statistical Brief, 2014 national data
These are national figures, and they say nothing about your mother or father in particular. What they show is that the first week home deserves a plan, while the discharge folder is still on the counter and the daily routines are being rebuilt. That’s why Endurance Homebound is a plan for the first 72 hours, and that’s the week we staff first.
what to watch in the first 72 hours home
What does Medicare pay for after a hospital stay?
The visits it covers
Medicare covers home health services only for people who need part-time or intermittent skilled services and who are homebound. That means nursing or therapy, ordered by a clinician and provided in visits on the agency's schedule.
What it doesn't cover
Medicare's home health benefit doesn't pay for 24-hour-a-day care at home. Families often hear the words home health and expect someone to be in the house. The benefit is for visits.
The hours in between
The covered visits take care of the nursing and therapy. The rest of the day is up to the family: meals, bathing, reminders, the ride to the follow-up, and someone to be there.
Many families use both
Skilled visits on their schedule, everyday help on yours. Ask the discharge planner which agency is providing the skilled visits and on which days, then plan the hours of help around them.
Coverage terms above are stated from the federal program’s own page. Medicare.gov home health services, retrieved 2026
questions to ask the hospital discharge plannerWhat kind of help does your parent need?
Start with what’s hard right now. Each line below is a kind of help our caregivers provide, and you can choose the ones that fit.
We provide personal care in Connecticut and New Jersey. In New York we provide companion care, by the hour, overnight, live-in or around the clock.
What is hard right now
- Getting washed and dressedPersonal careHands-on help with bathing, dressing and moving safely from room to room.
- The kitchen and the laundryHomemakingMeals, light housekeeping and laundry, so the kitchen works again.
- The hours aloneCompanion careConversation and company, which the first weeks are often short on.
- Keeping to familiar routinesMemory support at homeFamiliar routines kept steady while things settle down.
- Getting to the follow-upTransportationRides to the appointment, the pharmacy and back home again.
- Remembering medicinesMedication remindersA reminder at the right times, following the discharge instructions.
- Not being aloneSafety supervisionSomeone nearby while strength and confidence come back.
Most families need a few of these, and the mix often changes after the first week or two. Recovery from surgery often leans on rides and personal care, which is why home care after a hip replacement looks different from a recovery that started with a fall. Before the discharge, walk the list against a hospital discharge checklist for an elderly parent so the gaps are named while there’s still somebody at the hospital to ask.
Two things built for the first days
Both are ours, and both are there to make the first days home easier to organize.
Program
Endurance Homebound
Our hospital-to-home program, a plan for the first 72 hours after discharge. It covers meals, reminders, getting around safely and company during the days that are hardest to organize.
the Endurance Homebound program72
Hours the program plans for, counted from the day your parent comes home.
Optional layer
Endurance Technology Solutions
Optional 24/7 virtual care using 100 percent audio technology. It listens for events, not conversations, and if something happens it alerts Endurance so the team can respond promptly. The family decides whether to use it.
How the first weeks usually go
Every recovery is different, but most follow a similar path. We plan the help around your parent’s discharge date and adjust it as things change.
Discharge day
Tell us the discharge date when you call, and we'll plan the help around it.
The first night
Someone in the house overnight, awake if your parent needs help during the night.
The first weeks
Meals, bathing, reminders and rides to follow-up appointments, on a schedule you set and can change.
Steady again
As strength comes back, the hours can come down. The care plan is reviewed as needs change.
What does the cost depend on?
$6,864
In home care in Connecticut at 40 hours a week, per month.
Long Term Care Navigator, 2026 Connecticut figures.
$9,118
Connecticut assisted living, median monthly cost.
Long Term Care Navigator, 2026 Connecticut figures.
$15,208
A semi-private nursing home room in Connecticut, per month.
Long Term Care Navigator, 2026 Connecticut figures.
The cost depends on the hours of help, the kind of help and where your parent lives. Many families need more help in the first weeks and less as strength returns, so the cost often changes over the recovery. The figures above are useful for direction, not as a quote: a facility bills a month whether the month is hard or easy, and hours bill only for the hours. Endurance is private pay and doesn’t bill insurance directly, and Medicare doesn’t pay for ongoing daily help at home.
If there’s a long-term care insurance policy, families can use it, and we help with the policy paperwork. Bring it to the consultation and we’ll read it with you. Once we know the schedule, we’ll explain what it would cost. Read more about how families pay for care.
Questions families ask
What is transitional care after a hospital stay?
Transitional care is everyday help at home in the weeks after a hospital stay: help getting washed and dressed, meals, medication reminders, rides to follow-up visits and someone nearby while strength returns. It works alongside any home health visits the doctor has ordered for nursing or therapy. Endurance Home Care provides it by the hour, overnight, live-in or around the clock, and through Endurance Homebound, our plan for the first 72 hours home.
Is transitional care the same as Medicare home health?
No. Medicare home health is skilled care: nursing or therapy that a health care provider orders, in part-time visits for people who are homebound. Transitional care from Endurance is everyday help between those visits, such as bathing, meals, reminders, rides and someone nearby. Many families use both at once. Medicare's home health benefit doesn't pay for 24-hour care at home.
How fast can home care start after a hospital discharge?
Call our care team at (203) 936-6847, or (973) 315-5323 in New Jersey, and we start from there. Families describe being matched right away with an aide, and say the owner made everything easy from the very first call. We don't publish a fixed timeline. Tell us the discharge date on that first call, and the help you think your parent will need, and we build around it. The next step is a visit at home from one of our registered nurses, who writes the care plan with you.
Tell us when your parent is coming home.
Share the discharge date if you know it, and what the first weeks need. We’ll talk it through and explain the next steps. The first conversation is free, and nothing starts until you say so.