Discharge planning for advanced personal care patients is rarely straightforward. When a client presents with complex mobility limitations, cognitive decline, fall risk, and/or medication management challenges, traditional part-time home care may not provide adequate support.

In these scenarios, 24/7 care is not simply a convenience — it becomes a safety strategy.

The following case-based example illustrates how continuous care can stabilize high-risk situations while supporting families and referral partners.

Case Example: Stabilizing a High-Risk Discharge

A client was referred following a prolonged hospital stay involving multiple complications. Upon discharge, the individual presented with:

• Significant mobility limitations
  
  
• Increased fall risk
  
  
• Cognitive fluctuations
  
  
• Complex daily care needs
  
  
• Family members unable to provide round-the-clock supervision
  
  

While the client did not require skilled nursing, the level of supervision required exceeded what intermittent care could safely provide.

A 24/7 care model was recommended to ensure environmental safety, consistent monitoring, and continuity of support.

Why Advanced Personal Care Situations Often Require Continuous Care

High-acuity home care cases frequently involve overlapping risks that compound quickly without supervision.

Common indicators for 24/7 support may include:

• Nighttime disorientation or wandering
  
  
• Frequent transfers or mobility assistance
  
  
• Elevated fall probability
  
  
• Inconsistent medication routines
  
  
• Cognitive impairment affecting judgment
  
  
• Limited family availability
  
  

Without structured coverage, gaps in supervision can increase the likelihood of injury, setbacks, or avoidable hospital returns.

Rotating Care Model

Selecting the appropriate staffing model is a critical component of advanced personal  care planning.

Rotating 24/7 Care Model

Multiple caregivers work structured shifts to provide uninterrupted coverage.

This approach is especially beneficial when someone:

• Needs help multiple times during the night
  
  
• Has changing or unpredictable care needs
  
  
• Is living with memory loss or behavioral changes
  
  
• Has an increased risk of falls or other safety concerns
  
  

Rotating care ensures caregiver alertness while maintaining safety during high-demand periods.

Continuity of Caregivers in Complex Cases

In advanced personal care environments, caregiver continuity directly impacts stability.

Consistent caregivers support:

• Predictable routines
  
  
• Familiarity with client preferences
  
  
• Early recognition of behavioral or functional changes
  
  
• Reduced client stress and confusion
  
  

For referral partners, continuity often translates into fewer disruptions and more reliable outcomes.

Reducing Readmission Risk Through Structured Support

While many factors influence hospital readmissions, environmental instability and care gaps are common contributors.

Continuous care can assist by:

• Supporting consistent daily routines
  
  
• Helping clients adhere to discharge instructions
  
  
• Monitoring for changes in condition or behavior
  
  
• Assisting with mobility and safety needs
  
  
• Reducing caregiver fatigue within families
  
  

Importantly, non-medical home care does not replace clinical treatment. Instead, it reinforces safety, structure, and daily support — elements that frequently influence recovery trajectories.

Coordination in Advanced Personal  Home Care

High-acuity cases demand more than staffing alone. Effective support requires coordination among:

• Families
  
  
• Discharge planners
  
  
• Care managers
  
  
• Fiduciaries
  
  
• Healthcare providers
  
  

Clear communication, adaptability, and proactive problem-solving become essential components of care delivery.

When 24/7 Care Becomes the Safer Option

Not every client requires continuous care. However, when risk factors converge, structured 24/7 support often becomes the most reliable strategy for maintaining safety and stability at home.

For referral partners navigating complex discharges, early evaluation of supervision needs can prevent avoidable crises, injuries, and transitions back to acute settings.



Supporting Complex Care Transitions

High-acuity home care requires careful assessment, thoughtful staffing models, and consistent caregiver continuity. When properly structured, continuous support can stabilize vulnerable clients while easing the burden on families and care teams.

Assistance In Home Care works closely with hospitals, geriatric care managers, and fiduciaries to develop care plans aligned with each client’s functional, environmental, and supervision needs.