Discharge Home Safely With 24-Hour In-Home Care

A safer transition from skilled nursing, rehabilitation, or the hospital to home

24-hour care available throughout the Portland metro area.

Leaving a skilled nursing facility, rehabilitation center, or hospital can feel like a major milestone. But for many older adults, the first days and weeks at home are also the most vulnerable.

Medications may have changed. Mobility may be limited. Confusion can increase in an unfamiliar routine. Family members may not be able to provide overnight supervision, personal care, transportation, meals, and medication reminders around the clock.
Dwell Care provides coordinated in-home care that can begin the same day your loved one returns home.
Our caregivers can meet your family at discharge, help your loved one settle in safely, and provide continuous support while they regain strength and establish a stable routine.

Services can start as soon as
Round the clock care
Top caregivers

24-Hour Discharge Specialists

Dwell Care is more than just a top caregiver agency.
We specialize in helping older adults transition safely from a hospital, skilled nursing facility, or rehabilitation center back into their own homes.
Our role is to bridge the gap between clinical care and everyday life.

  • Coordinating the discharge plan with the family
  • Meeting the client at the facility or at home
  • Providing transportation assistance
  • Helping organize the home before arrival
  • Preparing meals and supporting hydration
  • Assisting with bathing, dressing, toileting, and mobility
  • Providing medication reminders
  • Monitoring for meaningful changes in condition
  • Supporting overnight safety
  • Communicating with family members
  • Coordinating with home health, hospice, therapy, and physician teams
  • Increasing or reducing care as needs change
hospice caregiver helping patient at home in Portland

Whether your loved one needs several hours of help, overnight supervision, or continuous 24-hour care, Dwell Care can create a plan around the discharge date.

Common Discharge Situations We Support

Skilled nursing and rehabilitation discharge
For clients returning home after short-term rehabilitation, orthopedic surgery, illness, or injury.
Hospital-to-home care
For older adults who need immediate supervision and daily support after hospitalization.
Dementia and memory-care transitions
For clients whose confusion, agitation, or safety risks may increase during a change in environment.
Stroke recovery
For clients who need assistance with mobility, personal care, communication routines, and daily activities.
Fall or fracture recovery
For clients returning home after a hip fracture, fall, joint replacement, or mobility-related hospitalization.
Hospice discharge
For families bringing a loved one home with hospice who need additional hands-on and overnight support.
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What the First Days at Home May Look Like

Every discharge is different, but a typical transition may include:

Before discharge

  • Initial consultation with the family
  • Review of the expected discharge date
  • Discussion of mobility and personal care needs
  • Coordination of the caregiver schedule
  • Identification of immediate home safety concerns

Day of discharge

  • Caregiver arrival at the scheduled time
  • Assistance entering and settling into the home
  • Meal preparation and hydration support
  • Personal care and toileting assistance
  • Medication reminders
  • Family update

First 72 hours

  • Close supervision
  • Support with transfers and walking
  • Monitoring for changes in routine or behavior
  • Appointment preparation
  • Overnight assistance when needed
  • Communication with the family and care team

Ongoing recovery

  • Continued personal care
  • Companionship and reassurance
  • Transportation and errands
  • Support with home exercises as directed
  • Care-plan adjustments
  • Gradual reduction in hours when appropriate
Care manager in green shirt sitting behind laptop with dwell care logo

Refer a patient to Dwell Care

To begin a referral, provide:

  • Patient or family contact information
  • Expected discharge date
  • Current location
  • General level of assistance needed
  • Preferred timing for a call

Our care team will contact the family promptly and guide them through the next steps.

Submit a Referral

For Skilled Nursing Facilities and Discharge Planners

Discharge planners often face the same challenge: a patient is medically ready to leave, but the family is not prepared to provide the level of support needed at home.

Dwell Care helps bridge that gap.

We work with discharge teams to coordinate private-pay in-home care for patients who need:

  • Same-day or rapid-start care
  • 24-hour supervision
  • Overnight support
  • Dementia care
  • Fall-prevention support
  • Personal care assistance
  • Hospice support
  • Short-term recovery care
  • Long-term in-home care

Our team can communicate directly with the family, explain care options, coordinate the start date, and help reduce the burden on facility staff.

Why Families and Healthcare professionals trust Dwell Care

✅ Fast response

We understand that discharge timelines can change quickly. Our team works to coordinate care as efficiently as possible.

✅ Flexible scheduling

Care may begin with 24-hour support and decrease as the client becomes stronger and more independent.

✅  Consistent communication

We keep designated family members informed and raise concerns when the client’s needs change.

✅ Experienced caregivers

Our caregivers assist with personal care, mobility, meals, companionship, transportation, and daily routines.

✅ Collaboration

We work alongside home health, hospice, therapy, physician, and family teams to support a coordinated plan.

Star Star Star Star Star

We chose Dwell Care to be with my Mom in her home, when she went into Hospice Care. They were able to accommodate our 24/7 care needs immediately. Every Caregiver that came into our home was extremely caring, professional and reliable. It was a comfort knowing that there were trustworthy, competent people with my Mom when I couldn't be. I would recommend Dwell Care without hesitation.

Christine E.
Beaverton, OR

Frequently Asked Questions

Care may be available on the day of discharge, depending on the client’s needs, location, schedule, and caregiver availability. Contacting us before the discharge date gives us the best opportunity to create a smooth transition.

No. Some families use 24-hour care temporarily during the first days or weeks after discharge. Care hours can be reviewed and adjusted as the client’s condition changes.

Home health typically provides intermittent clinical services such as nursing, physical therapy, occupational therapy, or speech therapy when ordered by a medical provider. In-home care provides ongoing non-medical assistance with personal care, meals, mobility, supervision, transportation, companionship, and daily activities. Many clients benefit from both services at the same time.

Yes. Dwell Care can provide non-medical caregiving support alongside hospice services. Hospice provides clinical and end-of-life services, while our caregivers can assist with personal care, supervision, meals, comfort routines, and family respite.

Yes. Depending on the client’s needs and caregiver availability, Dwell Care can arrange overnight or 24-hour care.

Some long-term care insurance policies may reimburse eligible in-home care services. Coverage depends on the policy. Dwell Care can provide documentation to support the claims process when applicable.

Yes, Dwell Care is a Medicaid licensed agency. Medicare does not cover in home caregivers unfortunately.

Plan a Safer Discharge Home

The time to arrange support is before your loved one is sitting in the car waiting to leave the facility.

Speak with Dwell Care as soon as you know a discharge may be approaching. We will help you understand your options, determine the appropriate level of care, and coordinate a plan for the first day home.

Your loved one may be ready to leave the facility.

We help make sure the home is ready for them.
a woman smiling with her arms around her shoulders

Let Dwell Care bring comfort, dignity, and support to your home.

Get started right away

📞 (503) 388-9682
Contact Us

Dwell Care provides in-home care throughout the Portland metropolitan area, including:

Our services are designed to meet each client where they are—physically, emotionally, and medically.

  • Portland
  • Lake Oswego
  • West Linn
  • Tigard
  • Tualatin
  • Beaverton
  • Happy Valley
  • Milwaukie
  • Oregon City
  • Clackamas
  • Gresham
  • Surrounding communities
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