Transitional Care 101 - Keeping Your Senior Loved One Out of the Hospital

Few things are more stressful than receiving a phone call that a family member is in the hospital. If your parent is elderly, a hospital admission can be even more worrisome. You want your senior loved one to be healthy and stay at home as long as possible, but a hospital admission can be the start of a series of health concerns and readmissions. Further, the high cost of a hospital stay and the risk of contracting serious hospital-acquired illnesses exacerbate the worry over a hospital admission. That’s why, if your loved one is admitted, it is imperative to reduce hospital readmissions. Taking steps towards securing essential transitional care upon discharge can make a significant impact on your loved one’s health and help avoid costly readmission.

Hospital Readmission Rates

It is quite common for elderly patients to be repeatedly readmitted. Reports have found that readmission rates can be anywhere from 11 to 23 percent within the first 30 days after discharge for those 65 and over. To truly understand the financial impact on families, these readmissions account for $15 billion in healthcare spending annually.

The Medicare Payment Advisory Commission (MedPAC) has found that up to 75 percent of these readmissions may be avoidable. MedPAC reports that reducing readmission rates by just 10 percent could result in $1 billion of savings. It’s not just the cost that matters; frequent hospital readmissions put your loved one at risk for life-threatening, hospital-acquired illnesses, such as pneumonia and Clostridium difficile colitis, a severe infection of the digestive tract.

Medicare, hospitals and the federal government are working together to reduce readmissions, lower healthcare costs and keep seniors healthier. To do this, Medicare has made hospital readmission rates publically available. Also, hospitals can be fined for high rates of readmission. Many hospitals have put programs in place to help with discharge planning and managing the health of those who are frequently admitted. According to the most recent MedPAC report, readmission rates have slightly decreased since these programs were put in place, but there is still more work to be done. 

Risk Factors for Readmission

Many risk factors increase the chances of readmission after discharge. A 2011 review of 11 studies on the subject found that a combination of socioeconomic status, chronic illnesses and mental disability all increased the likelihood of readmission. A few others that were identified in the study included:

• Previous hospital admission
• Long hospital stay
• Widowhood
• Social isolation
• Little family support
• Living in a home for the elderly
• Number of medications prescribed
• Mental problems, such as delirium and depression
• Lower socioeconomic status
• Healthcare usage before admission
• Diagnoses of chronic diseases, such as diabetes or heart disease
• Cognitive disability
• Frequent falls
• Incontinence

As you can see, the causes of readmission rates are quite complex and are influenced by many different factors. However, despite the complexity, there are several things you can do to keep your loved one out of the hospital.

The Importance of Transitional Care

Although hospitals can take many steps to reduce readmissions, by supporting families during discharge, it is still up to the family or patient to determine what will happen once they go home. Figuring out the level of care your loved one needs can be one of the most challenging parts of hospital discharge. Of course, doctors will always provide a discharge plan. However, rigorously adhering to it is often problematic, especially if you lack the time necessary to facilitate the plan. And that’s when transitional care can be of incredible assistance. 

Transitional care is care from one setting to another – in this case, the hospital to the home.

There are a few steps you can take to help. When your loved one is admitted to the hospital, start asking about discharge plans before literally taking your loved one home. With the amount of stress the entire family is under, it can take a long time to plan a safe discharge for a patient. Elderly patients can be easily overwhelmed when they are given lofty discharge instructions, so be sure to ask the hospital to make the directions as straightforward and easy as possible for your loved one, especially if you do not plan on being around to help execute the plan.

Before leaving the hospital, ensure that all necessary follow-up appointments are scheduled. Many hospitals use automated software programs to remind patients of appointments and lab tests that are necessary after discharge. It may be beneficial to inquire if this is available at your local hospital.

However, no matter what resources are available, your senior will likely need much help at home, not only to ensure he or she is adhering to the doctor's discharge plan but to help your loved one get back into a routine, back into the swing of things. And that's when superior home care can become an enormous asset.

Ready-Set-Go Home

Rigorously adhering to a discharge plan isn't easy for the senior or a family caregiver. However, the stakes are just too high to gamble on a lack of expertise. You need dedicated resources designed to solve for keeping your loved one safe and healthy at home, and out of the hospital.

One exceptional example of a dedicated, transitional care resource is the Visiting Angels Ready-Set-Go Home program. This unique program provides high-quality, non-medical transitional care and coordination during discharge. Ready-Set-Go Home is a three-pronged, customized approach aimed at helping reduce hospitalizations.

It doesn’t just start when you get home. It begins at the hospital, when discharge planning begins, to thoroughly assess your loved one’s needs, capturing vital feedback and insight from a doctor’s discharge plan. It also includes home visit services to help manage those important non-medical responsibilities of caring for your loved one, like completing simple tasks and ensuring a doctor’s discharge plan is followed. The last prong is office staff support, which can help you coordinate and manage all the different aspects of successful hospital discharge.

When it comes to hospital readmission, you certainly want to do the best you can to keep your loved one out of the hospital, but unfortunately not every readmission is preventable. Incorporating a few of the suggested strategies, including professional transitional care programs, can help lower the likelihood and keep your loved one healthy and at home.

Learn more about how to avoid costly hospital readmission by clicking here.