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Our In-Home Services & Support | HomeHealth - ChristianaCare
Support After a Hospital Stay, Right at Home
Recover safely at home after a hospital stay
Many patients qualify for home health care after a hospital stay to help reduce complications and prevent readmissions. If you’re homebound and need part-time skilled nursing or therapy services, Medicare and many insurance plans may cover care delivered where you live. ChristianaCare works closely with your hospital team, at any hospital you are discharged from, to help you transition safely and support your recovery.
Call or request a visit to get started today.
Who Qualifies & What’s Covered
Home health care is designed for patients who are homebound, under a physician’s care and need skilled nursing or therapy services to safely remain at home. Coverage, including Medicare and many insurance plans, depends on medical necessity and your specific benefits.
Home health disciplines may include:
- Registered nurse (RN): Clinical assessments, medication management, injections and monitoring.
- Physical therapy (PT): Strength, balance and safe mobility training.
- Occupational therapy (OT): Daily activities like bathing, dressing and home safety.
- Speech therapy (ST): Communication, cognition and swallowing support.
- Medical social work: Counseling, care planning and community resources.
Common skilled care needs we support:
- Post-surgical recovery
- Management of chronic conditions
- Fall prevention
- Medication management
Our team helps confirm eligibility, explains your coverage and coordinates services across these home health services so you can recover safely at home.
How It Works: From Discharge to First Visit
We make the transition of care from all hospitals to home clear and timely. Our team partners with your clinicians to turn your discharge planning into a safe, coordinated start at home.
- Referral sources: Your hospital team, physician or caregiver can request home health services. We confirm orders, eligibility and insurance quickly.
- Start-of-care timing: The first visit is scheduled as soon as possible – often within 24–48 hours after discharge – based on your clinical needs.
- Visit cadence: Care consists of short, scheduled visits. Frequency is set by your clinician and adjusted as you improve.
- Communication: We share updates with your doctor, reconcile medications and flag changes early to prevent setbacks or readmissions.
- Caregiver role: Family or caregivers support daily routines between visits. We teach skills, provide clear instructions and offer a direct line for questions.
From referral to first visit, our home health team keeps your transition of care organized, responsive and focused on a safer recovery at home.
Talk to a nurse today by calling 888-862-0001 or fax a physician referral to 302-325-7075.
Your In-Home Care Team
Your care is led by a coordinated home health team focused on safe recovery, clear communication and timely follow-up.
- RN lead: Oversees your plan of care, performs clinical assessments, manages medications and coordinates with your physician.
- Physical therapy (PT): Builds strength, balance and safe mobility to reduce fall risk.
- Occupational therapy (OT): Supports daily activities like bathing, dressing and home safety.
- Speech therapy (ST): Helps with communication, cognition and swallowing when needed.
- Medical social work: Assists with counseling, care planning, and connections to community resources.
If your condition changes, we promptly notify your provider, adjust your plan and arrange urgent care or readmission if needed.
Benefits & Outcomes
Home health supports a safer recovery where you’re most comfortable (your home) while helping prevent readmission through close monitoring and early action.
- Recover at home: Personalized, clinician-led care that fits your routine and goals.
- Fewer complications: Early identification of changes, medication checks and wound monitoring to reduce risks
- Prevent readmission: Timely visit, education and coordination with your doctor to help avoid unnecessary hospital returns.
- Better patient experience: We focus on clear communication, respect and responsiveness – key patient experience measures (CAHPS), including how well we explain care, listen to concerns and manage medications.
- Caregiver support: Practical training and guidance so families feel confident between visits.
Our approach combines clinical oversight with compassionate support to improve outcomes and strengthen the overall patient experience at home.
Costs & Insurance
We help you understand Medicare home health benefits and other coverage so you can focus on recovery instead of paperwork.
- Coverage types: Medicare, Medicaid, and many commercial plans may cover home health when criteria are met (physician order, homebound status and need for intermittent skilled care).
- 30-day period of care: Under Medicare, services are organized in 30-day periods based on your needs; visits and services are adjusted as you improve.
- What’s typically included: Skilled nursing, PT/OT/ST, and medical social work; medical supplies for your care plan may be covered.
- What’s not included: 24/7 custodial care, meal delivery or housekeeping.
Our team verifies benefits, explains any out-of-pocket costs and keeps your plan aligned with your coverage.
Hospital-at-Home vs. Home Health
Both services support care at home, but their scope and expectations differ.
- Scope differences: Hospital at Home delivers hospital-level care in a patient’s home (daily clinician visits, remote monitoring and rapid labs or imaging). Home health provides part-time, skilled visits (RN and therapy) focused on recovery, education and stabilization after discharge.
- Availability limits: ChristianaCare’s hospital care at home program is offered only for certain conditions and locations and requires strict eligibility. Home health is more widely available when you’re homebound and have a physician’s order for skilled care.
- Expectation-setting: Hospital-at-home is short-term, high-intensity care that substitutes for an inpatient stay. Home health is lower intensity, longer duration and supports a safe transition of care with clear goals and follow-up.
Get Started with Home Health
Starting home health is simple. We guide you from the first call to your first visit.
- One form or phone call: Submit a referral or call us directly to begin.
- What to have ready: Patient name, date of birth, address, insurance details, physician contact, recent hospital and discharge information and medication list.
- Care area & hours: We serve patients in the state of Delaware with flexible scheduling; start-of-care is prioritized based on clinical need. We have 2 agency offices in Wilmington and Smyrna.
Call 888-862-0001 or fax a physician referral to 302-325-7075 to discuss your home health needs.
Frequently Asked Questions
ChristianaCare’s Hospital Care at Home program provides many of the same services patients would receive during a traditional hospital stay, delivered safely at home. Covered services may include physician-led care, 24/7 remote monitoring, nursing visits, telehealth check-ins, lab testing, mobile imaging, IV therapy, medication management, wound care, physical and occupational therapy, medical equipment and care coordination. Coverage depends on medical eligibility, physician approval and your insurance plan, with standard deductibles, copays or coinsurance applying based on your benefits.
Contact Us
New Castle County Office
Kent and Sussex County Office
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