During the weeks following a hospitalization, seniors are especially vulnerable to complications. Adverse reactions to medications and complications related to the hospitalization affect nearly 20 percent of patients, leading to hospital readmission. Proper discharge planning from hospital to home is essential.

Seniors who are readmitted to the hospital share common characteristics. These older adults usually suffer from multiple chronic health conditions. Stroke patients are readmitted due to cardiac diseases as well as non-cardiac illnesses, such as urinary tract infections, hip fractures and pneumonia.

Readmission to the hospital can be prevented, especially if the older patients have access to outpatient care and adequate social support at home. Causes of readmission include gaps in care coordination, the absence of timely medical follow-ups and insufficient discharge instructions.

What elderly patients need most is a transitional care strategy prepared prior to discharge from the hospital setting. Included in the transitional care strategy are an assessment of risks that may lead to readmission, caregiver or patient education and a patient record (in lay language) for patient use.

After the hospital discharge, seniors will benefit from outreach. The post-discharge intervention includes follow up phone calls to assess the patient’s health, hotlines activated by the discharged patient and care visits to the home setting. Medication reconciliation is extremely beneficial.

Care Transitions Intervention

A care transitions intervention may be followed to ensure a safe shift from hospital to home. Medication management, a personal health care record that may be accessed from site to site, timely follow-ups with primary care doctors and knowledge of red flags are integral to a successful intervention.

A care transitions intervention will involve a transition professional, such as a registered nurse. The nurse practitioner will be responsible for conducting post-discharge home visits. Phone calls that emphasize self-care techniques to treat chronic illnesses are also made by the transition coach.

Transitional Care Model

Another successful program that has shown to reduce hospital readmission is the transitional care model. A transitional care nurse is heavily involved in the senior’s post-discharge routine. This medical professional follows the elderly patient from the hospital to the home environment.

The transitional care nurse performs several healthcare tasks, including facilitating communication between outpatient providers. During the post-hospitalization period, the nurse visits the senior at home to evaluate health and makes several phone calls to follow up on the patient’s condition.

Project Re-Engineered Discharge

A third program that has seen positive results for seniors released from the hospital is the project re-engineered discharge. A nurse discharge advocate engages with the senior patient during the hospitalization and prepares a post-hospitalization plan. After discharge, a pharmacist reviews prescription medication.

The implementation of these transitional care programs reduces hospital readmission rates. The care transitions intervention significantly reduces 30-day rehospitalizations. The transitional care model reduces readmission rates at 60 and 90 days. Project re-engineered discharge has also seen lowered hospital readmission rates.

All three programs contain similarities, with a healthcare advocate being central to each. A transition provider, such as a nurse or case manager, is critical to the discharged patient’s successful transition to home. Outreach and coordinating care are also among the most effective strategies.

While evidently effective, the three aforementioned transition care programs require a series of resources. Studies are currently underway to determine financial costs, implementation and sustainability. But discharged patients always have the option to turn to home care providers for quality post-hospitalization support.

Home Care Support

Families who develop an elder care plan post-discharge help to significantly reduce the chances of rehospitalization. Hiring a professional caregiver for 24/7 support will ensure that the senior receives substantial care at home, especially during the critical 30-day post-hospitalization period.

An in-home caregiver can help in numerous ways. Professional caregivers assess the home environment so that it is free from fall risks. Clutter is removed and walkways are cleaned. Overexertion at home can trigger the relapse of a medical condition or lead to a new injury.

Seniors who are weakened after a hospitalization receive plenty of support from in-home caregivers. These professionals provide assistance with mobility, such as helping the senior get into and out of bed, assisting seniors who are wheelchair bound and providing overall physical support.

Injury can also lead to weakened states and necessitate modifications at home. Family members or caregivers can facilitate the transition to home by installing grab bars in the bathroom, non-slip rugs on the floors, hand rails along both sides of the stairs, and ramps along the steps.

Prescription medications save lives, but drugs taken in the wrong doses can lead to a hospital readmission. Due to the risks involved in medication noncompliance, it is imperative that discharged seniors or their caregivers understand when to take the medicines and in the exact doses.

One of the many responsibilities of a professional caregiver is to provide timely medication reminders. Although a non-medical home care provider is unable to administer medications, a caregiver will make sure the senior takes the right medication dosage at the scheduled times.

A successful transition from the hospital setting to a home environment requires support. When your elderly loved one is about to be discharged, choose Assisting Hands Home Care for reliable in-home assistance. Our caregivers are experienced, skilled and qualified to provide non-medical elder care.

Assisting Hands Home Care providers will transport seniors to their doctor’s appointments, physical therapy sessions and to the pharmacy to pick up medications. We also shop for groceries and prepare nutritious meals. A vitamin-rich diet provides the nutrients the body needs to heal.

Our after surgery care includes medication reminders. We also perform light chores so that our care recipients live in a hygienic environment. Assistance with the activities of daily living, such as bathing, grooming and dressing, is a core responsibility of our professional caregivers.

Whether your elderly loved one will benefit from 24/7 care, respite care or long-term care, Assisting Hands Home Care will customize a post-operative care plan to meet those needs. We are available to serve seniors and recuperating patients living in Naperville, Glen Ellyn, Lisle, Wheaton and surrounding areas in Illinois. Call us at (630) 352-3656 for a free in-home consultation.