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The Journey From Hospital to Home – One of the Most Critical Moments in Patient Recovery
Hospital-to-Home Transition: A Bridge to Recovery
ieadvocates
January 13, 2026
Working Caregivers-The Invisible Employees Newsletter
Brought to you by ieAdvocates (invisible employee advocates)
Thank you for being here!
The journey from a hospital stay to home is often treated as an endpoint – but in reality, it’s one of the most important moments in a patient’s care. Without thoughtful planning and support, this transition can quickly lead to complications, confusion, and avoidable readmissions.
In this issue, we discuss why hospital-to-home transitions matter, the hidden risks that can occur after discharge, and the essential role that caregivers, advocates, and employers play in promoting safe recovery. Ultimately, hospital-to-home transitions are not a single event – they are a process. With the right support, preparation, and awareness, this critical phase can become a bridge to recovery rather than a pathway back to the hospital.
Table of Contents
In the news:
Latest research, events, and articles that are making an impact for working caregivers and their employers.
Programs for Advance Care Planning, Care Transitions, and Caregiver Support
Explore these evidence-based programs from powerful caregiver tools to ways of aging in place, that address advance care planning, care transitions, and caregiver support.
Managing Caregiving Transitions from Hospitals to Skilled Nursing, Rehab or Assisted Living and Back Home
by Amy Goyer, AARP's family caregiving expert, October 27, 2021 and updated May 30, 2025, VeteransNavigator
Amy Goyer has helped many caregivers manage their loved ones’ transitions between hospitals, rehab, skilled nursing facilities, assisted living and home. Family caregiver transitions can be difficult and stressful. Caregivers play a crucial role in easing transitions, advocating and ensuring that loved ones adjust and get appropriate care along the way.
Family caregivers are the only consistent people on loved ones’ care teams . Amy shares ways caregivers can plan for transitions proactively.
Read the article here.
Did you know? (Read our blog):
Our blog brings you knowledge, personal and researched, to raise your awareness and empathy about working caregivers and caregiving.
Why Hospital-to-Home Transitions Matter: A Critical Moment for Patients, Families, and Employers
by Zack Demopoulos
Zack’s mom during a recent hospital visit
One of the hardest parts of being a long-distance caregiver like I am for my mother, who is over 600 miles away, is hospitalizations. My mom is 96 years old, hard of hearing (even with hearing aids), and English is her second language. For these reasons and many others, she always needs an advocate with her when health issues arise. Without proper advocacy, the risk of miscommunications, misdiagnosis, overtreatment, delayed discharge, and less-than-adequate care increases.
A Moment in My Care Journey
As we start into a new year of caregiving, I thought I would share a critical moment from my personal care journey. I already mentioned that I am a long-distance caregiver, right? Well, a week before Christmas, my mother was admitted to the hospital for atrial fibrillation, congestive heart failure, dehydration, and UTI. With the pending holidays, a growing shortage of staff, seasonal flu, and other viral episodes, getting someone on the phone to get status updates or trying to return a call to a physician who left me a message while I was in a meeting was extremely difficult.
People and Companies In the spotlight:
Our podcast puts a spotlight on guests who are making a significant difference in the working caregiver space.
Episode 32: Veteran Caregiver Benefits That You Most Likely Do Not Know About With Erika Jacobson
In this episode of Working Caregivers: The Invisible Employees, we’re joined by Erika Jacobson, a VA social worker, lifelong caregiver, and member of the sandwich generation, to unpack what caregiving really looks like inside veteran families. Erika blends professional insight with personal experience to help us understand why so many working caregivers feel isolated—and how support systems can make a real difference.
We talk through the VA’s Caregiver Support Programs, benefits many families don’t know exist, and why employers play a critical role in supporting caregivers at work. This episode is packed with practical information, advocacy, and a reminder that caregivers shouldn’t have to do this alone.
Erika Jacobson is a licensed clinical social worker and substance use counselor in Sioux Falls, SD. She serves Veterans and Caregivers as the Sioux Falls VA Health Care System Caregiver Support Program Manager and supervisor of the Behavioral Recovery Outreach (BRO) Team. She has two master’s degrees, one in social work and the other in social gerontology from the University of Nebraska Omaha. She is pursuing a doctorate in social work and is a caregiver of her disabled sister and father who is a disabled Veteran.
Meet Brittany Hogan, a real working caregiver:
Brittany Hogan
It was a very tough journey. It was very hard. And I know it wasn't as long as a lot of people's, but it was still very difficult outside of all of the medical issues, outside of the constant heartbreak of you think it's getting better and then it doesn't and she's working… but they're like, it doesn't matter what she does, it's never going to get better. The emotional toll of that, but also the fight to be heard, the fight to be seen, the fight to be recognized as somebody with a voice. That was a very big component of my journey. And that's what led me to try to create the solution that I'm working on now.… ”
Brittany L. Hogan is a Chicago native whose caregiving journey began when she cared for her mom through numerous complex medical conditions. Navigating those experiences opened her eyes to how confusing and overwhelming the healthcare system can be, especially for families trying to make the right decisions under pressure. Wanting to make that journey easier for others, she founded FairGiver, an app designed to bring more clarity and confidence into medical conversations. Brittany has since become an advocate for people who feel just as lost as she once did, using her perspective to help families feel more informed, supported, and seen. Connect with Brittany on LinkedIn.
“ I've come across a lot of different caregiving tools now, which at the time I had no idea they existed. So I feel like it would be good for employers who are considering caregivers to be informed about what's out there and what could help… them and their family… to where it’s a more even temperament. They don’t have to feel that added pressure because it’s already chaos. You're trying to keep somebody alive or get them better and you’re thinking about, I got to get back to work before they fire me… That's a pressure that people shouldn't have to deal with because they're already under enough pressure, which goes right to our vision, not having to choose between your loved one and your job…”
Recommended media content:
We explore and share with you diverse media illuminating the dynamics and narratives within the care economy - from insightful podcasts to thought-provoking books and engaging videos.
PODCASTS
The Mayo Clinic Aging Forward Podcast. From Hospital to Home: Mastering Transitions of Care and Preventing Re-hospitalizations. Physically moving from one healthcare setting to another -- whether it be from the hospital to rehab, or rehab to nursing home -- can be a complicated process, both logistically and emotionally. And in the midst of all of that hubbub, it can sometimes be hard for the person in the center of it all to feel like they're properly being heard.
On this episode of Aging Forward, Dr. Maria De la Garza talks about the commonality of communication errors between health providers during care transitions, the importance of caregivers and loved ones in the process, a how to center the patient and their wishes in their care.
BOOKS
Is your loved one's serious illness causing you to feel overwhelmed or powerless? Do you desperately want them to get the care they deserve but aren't sure where to begin? Are you looking to make sense of the chaos surrounding their health issues?
In this information-packed and action-oriented book, you will learn how to lead the charge and powerfully advocate for the patient in your life. Whether your loved one is hospitalized or home-bound, Badass Advocate will teach you how to effectively navigate the challenges you face.
After losing her father and sister to aggressive diseases, Erin Galyean learned what it takes to powerfully advocate. In Badass Advocate, she shares what she learned so you can make a difference in your loved one's care.
VIDEOS:
This is an excellent film about compassion and the critical role of social work. The Phoenix," a film from South Dakota Social Worker Erika Jean Jacobson (March 27, 2025), is winner of the 2025 Social Work Month short form documentary contest. Jacobson is a licensed clinical social worker and substance use counselor in South Dakota. She obtained her MSW as well as a master in social gerontology from the University of Nebraska at Omaha. She is currently pursuing her doctorate in social worker from the University of Kentucky.
We want to thank Peruser. who took the time to read our book and provide a thoughtful ⭐⭐⭐⭐⭐review!
“This book vividly illuminates the challenges so many employees face in balancing the demands of work with the need to support family members. And it offers essential guidance for employers on how to create a caring culture through programs, policies and leadership behavior. I highly recommend this book to any working caregiver. It is also an invaluable primer for any manager who wants to learn how their organization can help their employees succeed in their professional responsibilities by helping them meet their personal obligations..”
Order your copy of Working Caregivers-The Invisible Employees book here. If you want to order a quantity of books for your leadership team and employees, contact us directly about discount pricing.
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