Post-Hospital & Post-Surgical Home Care

Maryland, Washington DC, and Northern Virginia

Post-Hospital & Post-Surgical Home Care

Coming home after a hospital stay or surgery? Our nurse-led post-hospital & post-surgical home care keeps recovery on track with meds, wound care, safe mobility, and follow-ups – from a few hours a week to 24/7 care! 

When your loved one returns home after a hospital stay or surgery, it’s a relief - but the next 30–90 days are critical. Many families need extra hands to manage new meds, wound/incision care, mobility, and fall risk, pain control, and follow-up appointments so recovery can stay on track. 

Our RN-led post-hospital & post-surgery home care brings hospital-level skill into the home and wraps it with calm, dependable support with anywhere from occasional respite support to 24/7 care depending on your needs. 

Post-Hospital & Post-Surgery Patients & Conditions We Serve 

We serve patients who’ve recently been discharged from a hospital or surgery with these health conditions/procedures: [1] [2] 

• Heart Failure & Heart Disease 
• Pneumonia 
• COPD 
• Diabetes  
• Sepsis 
• Strokes 
• Kidney Disease 
• Cancer 
• Parkinson’s 
• Seizure & Epilepsy 
• Joint Injuries 
• Chronic Pain (especially back, knees, and hips) 
• Surgeries/Procedures: 
• Total hip/knee arthroplasty (joint replacements) and hip-fracture repair [3] 
• Coronary artery bypass grafting (CABG) [4] 
• Other frequent triggers: coronary stent/PCI, major abdominal surgery (Ostomy), and spine procedures. 

In-Home Care After Discharge is Common: studies show more than 40% of those discharged from a hospital receive in-home care for 90-100 days. [5] 

How We Provide Care 

In-Home Nursing: 

• Medication Management, Reminders, & Administration 
• Wound & Injury Care 
• Dysphagia Management 
• Ostomy & Stoma Care 
• Catheter Care 
• Tube-Feeding & Nutrition Support 
• Vitals and symptom monitoring 

Personal Home Care (Home-Health Aides): 

• Bathing, Dressing, and Grooming 
• Companionship Care 
• Fall-Prevention 
• Light Housekeeping and Laundry 
• Meal Preparation & Feeding Assistance 
• Post-Rehab Exercises 
• Errands Services & Shopping Assistance 
• Transportation & Appointment Escort for follow-up procedures or medical check-ins 
• Community/housing/benefits integration 

Respite Care 

• Short-term relief for family caregivers 
• Care provided in the home so loved ones can rest, travel, or attend to other responsibilities 
• Flexible scheduling to meet urgent or planned needs 

24/7 Care 

• Around-the-clock home support for individuals with high or complex care needs 
• Overnight monitoring to ensure safety, comfort, and prompt response to needs 
• Continuous personal care, companion care, and nursing oversight as required 

What Areas We Serve 

We provide care in Montgomery County, MD, Prince George’s County, MD, Frederick County, MD, Howard County, MD, Washington, DC, Fairfax County, VA, and Arlington County, VA for post-hospital and post-surgery patients. 

These areas have many hospitals and rehabilitation facilities that require an in-home care provider like us to meet their patients’ needs after discharge. We work directly with the social workers and case managers of hospitals and rehab centers to provide the most personalized and effective care possible. 

Professionals & Providers We Collaborate With or Recommend 

• Physicians & Primary Care (med rec, vaccine catch-up, care plan oversight) 
• Pharmacies (antibiotics, hydration, TPN when ordered) 
• DME Suppliers (beds, lifts, wheelchairs, oxygen, nebulizers) 
• Clinical Pharmacists (adherence packaging, interaction checks) 
• Medical Social Workers (benefits, transportation, caregiver grants) 
• Area Agencies on Aging (AAA) & local aging services (MD/DC/VA) 
• Palliative Care Providers (symptom control alongside curative care) 
• Hospice (when prognosis/goals align) 
• Transportation & Appointment Escort Services 
• Imaging & Lab Partners (mobile x-ray, home draws) 

How Our Process Works – Step-by-Step

1. Start with a thorough nursing assessment. 

Our nurses review your hospital/surgical discharge summary and physician orders, then visit your home to set a safe baseline. We check your medication reconciliation & setup, wound status lines/tubes/devices, mobility & fall risk, and vitals with a red-flag screening. 

2. We develop a personalized care plan 

Your nurse builds a personalized written plan that may assist with daily routines, clinical pathways, home-exercise/therapy carryover, a safety checklist, and vitals & symptom monitoring with clear escalation thresholds. 

3. Match you with a caregiver & schedule your care team. 

We pair you with the right mix of nurses and home health aides that meet your care needs and work within your schedule. 

4. Deliver care consistently 

Your team follows the plan every visit, so recovery can be steady and predictable. This can include nursing, personal care, respite care, and/or 24/7 care as needed. 

5. Regularly scheduled nurse check-ins 

Your nurse reviews progress regularly and updates the plan as needed, refers to external healthcare providers, or can escalate care due to red-flag symptoms. 

Sources 

1. Healthcare Cost and Utilization Project (HCUP-US). 
   https://hcup-us.ahrq.gov 
   Accessed September 2025. 
2. PubMed Central (PMC). 
   https://www.ncbi.nlm.nih.gov/pmc 
   Accessed September 2025. 
3. Centers for Disease Control and Prevention (CDC) – Total Hip/Knee Arthroplasty and Hip-Fracture Repair. 
   https://www.cdc.gov/arthritis/data_statistics/hip_knee.htm 
   Accessed September 2025. 
4. PubMed – Coronary Artery Bypass Grafting (CABG). 
   https://pubmed.ncbi.nlm.nih.gov 
   Accessed September 2025. 
5. JAMA Network – Post-Acute In-Home Care After Hospital Discharge. 
   https://jamanetwork.com 
   Accessed September 2025.