How We Reduce Hospital Readmissions

Comprehensive Transitional Care Your Key to a Smooth Recovery

Although you'll be happy when a parent or older relative is ready to return home after a long hospital or rehab stay, you may also have concerns. Will they be safe and healthy at home? Do they have the right resources to remain independent?

With a strong support system in place, your family member can flourish as they transition to new healthy routines, adjust to a medical diagnosis, or recover from surgery. When you work with the team at Visiting Angels Spokane, we'll help the whole family adapt before, during, and after hospital discharge with comprehensive transitional care services.

What Is Transitional Care?

The National Association of Clinical Nurse Specialists (NACNS) defines a transition as any situation where your family member leaves one care setting and moves to another. Transitions occur when a patient goes from one type of provider to another. This can include moving from a primary care physician to a specialist or to a different level of care or care setting, like from the hospital to a subacute rehab facility or home, or transitioning within the same care setting, like moving from the intensive care unit to a step-down unit in the same hospital.

Like all types of transitions, returning home after an extended hospital or nursing room stay may present challenges for your loved one. We think of transitional care as life-change care, giving our clients the tools they need to thrive in a new situation.

The NACNS emphasizes the importance of providing continuous care based on a personalized, comprehensive plan throughout the transitional time. This requires a concerted effort by the patient, family members, and caregivers.

Our Ready-Set-Go Program

Our Ready-Set-Go Home program covers the many care requirements of older adults before they leave the hospital and return home. We rely on a three-pronged approach:

1. First, our coordinators initiate the care process at the hospital to fully prepare care recipients and their family members for the discharge and recovery process.
2. When your loved one returns home, our caregivers visit to assist with daily routines and help them follow instructions from healthcare providers.
3. Our office staff members coordinate care, iron out logistics, and set reminders as necessary to ensure no detail is overlooked during your family member's recovery.

Even if your loved one still has a few weeks left until discharge, our caregivers can start visiting immediately so they'll have support from a familiar face throughout the transition. We can also ensure your family receives clear discharge instructions and help you follow them at home.

What Is a Readmission?

Lack of transitional care can increase a patient's risk of readmission. This occurs when the person experiences health complications that require a return to the hospital after discharge. Medicare members have about a 20% chance of readmission during the first 30 days back at home, significantly higher than the readmission risk for other age groups.

Factors that increase this risk for older adults include the following:

• Lack of support at home or in the community.
• Loss of strength and stamina after surgery or illness.
• Insufficient discharge plan.
• Failure to follow up with care providers.
• Severe chronic conditions, especially when the person has uncontrolled health complications.
• Poor nutrition.
• Difficulty understanding discharge instructions.
• Not taking medication or taking prescriptions incorrectly.
• Not following recommended infection-control measures.

If your family member has repeated readmissions, they may be unable to live independently at home. According to the Agency for Healthcare Research and Quality, seniors who spend extended time in the hospital experience physical complications, including bone, muscle mass, and mobility loss. They also have an elevated risk of injury from medication errors, falls, and fractures.

Fortunately, the right support system can dramatically reduce the risk of readmissions. Visiting Angels provides transitional care resources designed specifically for the needs of older adults as they age in place. One study published by the medical journal JAMA Network Open found that this type of transitional care decreased the risk of readmissions by about 170% among more than 32,000 study participants aged 75 to 90. Those who received supportive services during the transition also had fewer emergency room visits. The researchers noted that up to 67% of hospital readmissions could be avoided.

How Visiting Angels Helps Prevent Readmissions

When you enroll in transitional care with Visiting Angels, your loved one will have someone by their side when they return home. Our professionals specialize in lifestyle care, such as establishing comfortable routines, helping with healthy changes, and providing medication and appointment reminders. A systematic review published in BMJ Open indicated that seniors returning home from the hospital have the best outcomes if they receive supportive home visits for at least 30 days. In seven of the 11 studies analyzed, researchers found that transitional care positively affected outcomes for seniors moving from hospital to home. Three of the remaining studies showed no impact, and one was inconclusive.

Our experience in life-change care has given us a close look at the importance of aging in place for seniors in Spokane. As a result, we've designed our transitional care services to offer comprehensive wrap-around support that starts while your loved one is still in the hospital. Home visits continue after hospital discharge, providing the specific types of assistance your family member needs, whether that means receiving help with meals and household tasks or simply having a friendly, supportive companion.

Getting Started With Transitional Care

If you think your family member may benefit from transitional care, prepare now for a successful hospital discharge and transition back home. The team at Visiting Angels Spokane will conduct a free consultation so you can learn more about how our services can benefit your loved one. When you enroll your loved one in a care program, we'll create a personalized plan incorporating hospital and home visits to ensure a successful adjustment and reduce readmission risk.

Contact Visiting Angels today at (509) 922-1141 for your free transitional care consultation in Spokane Valley, Spokane, Millwood, Veradale, Cheney, Fairwood, Town and Country, or a neighboring community.