Preventing Readmissions Through Homecare: The “First 72 Hours” Stabilisation Model
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The first 72 hours: where discharge packages succeed or fail
If you ask experienced homecare managers where discharge packages go wrong, the answer is rarely “week 6.” It’s the first 72 hours: missing information, medication confusion, mobility mismatch, equipment delays, and unrecognised deterioration. This window is also where great homecare providers can make the biggest difference to outcomes and system flow — by stabilising people safely at home and preventing avoidable re-admission.
This is easiest to deliver when it’s treated as a defined pathway, not informal “extra checking.” If you want the wider context, link this approach to Hospital Discharge & Reablement and your broader Service Models & Care Pathways.
A practical 72-hour stabilisation model
1) Start with a stabilisation plan, not a full care plan
Traditional care plans can take time to perfect. Discharge packages often can’t wait. Instead, write a short stabilisation plan that covers:
- What “safe” looks like for the next 72 hours
- The highest risks (falls, dehydration, infection, confusion, pressure damage)
- The controls you will apply (double-up, call windows, prompts, welfare checks)
- Who to contact if things change (provider on-call, discharge hub, GP/NHS 111 as appropriate)
This creates clarity for staff and reduces improvisation.
2) Medication: treat discrepancies as a safety-critical risk
Medication is one of the most common drivers of early breakdown. In the first 72 hours, ensure:
- Medication list matches what is in the home
- Any blister packs/dosettes align with the current prescription
- MAR/eMAR is present and accurate before administration
- Clear boundaries exist between prompting vs administering
If anything doesn’t match, document the discrepancy and escalate. A “no MAR, no administer” rule (unless local protocol and safe verification exist) protects people and staff.
3) Hydration, nutrition and heat: the quiet causes of deterioration
Early deterioration is often linked to basic needs. Build simple checks into the first 72 hours:
- Is there accessible food and drinks in the home?
- Can the person prepare a drink safely? If not, what is the plan?
- Is the home warm enough and safe to move around?
- Are continence needs managed, and is toileting safe?
Small interventions here can prevent escalation later.
4) Mobility and transfers: confirm reality and adjust fast
Discharge notes can be optimistic. The first 72 hours should confirm:
- Whether transfers are safe with the planned staffing level
- Whether equipment is present, correctly fitted, and used consistently
- Whether fatigue changes mobility across the day
If the person needs double-up or additional calls, escalate immediately with evidence. “Right-sizing” the package early is safer and usually reduces total cost over time.
5) Deterioration triggers: give staff simple “red flags”
Build a short list of red flags into the stabilisation plan so staff act early:
- New/worsening confusion, drowsiness, or agitation
- Shortness of breath, chest symptoms, fever, or suspected infection
- New falls, near misses, or sudden reduced mobility
- Reduced oral intake, vomiting/diarrhoea, or dehydration signs
- Skin changes or pain suggesting pressure damage
Pair red flags with a clear escalation route and documentation standard.
6) Build “micro-reablement” into the stabilisation window
Even in the first 72 hours, you can support independence. Use micro-goals: “stand with support,” “walk to kitchen with frame,” “wash at sink with prompts.” This prevents drift into dependency and creates momentum for reablement.
7) 48-hour review: lock in the medium-term plan
At 48 hours, complete a structured review with the person/family where possible. Confirm:
- What has changed since discharge
- Which risks remain highest
- Whether call patterns and staffing are correct
- Whether this will step down (reablement) or stabilise into long-term care
Document decisions and communicate changes to the commissioner/discharge hub.
8) Evidence impact (so your model strengthens bids)
To demonstrate that your approach reduces readmissions, track a small set of measures:
- 72-hour package stability rate (no unplanned breakdown)
- Medication discrepancies identified and resolved
- Number of early escalations (and outcomes)
- Readmissions within 7/14 days (and learning themes)
Bottom line
The first 72 hours is where discharge homecare delivers the biggest value. A clear stabilisation model — medication discipline, basic needs checks, red flags, rapid escalation and a 48-hour review — protects people and helps the system. It’s also a compelling story for commissioners when backed by simple evidence.
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