Help for Senior Caregivers: How to Avoid Hospital Readmission

home care services for seniors home help for the elderly in home care Minneapolis in home help for seniors in home senior care providers non medical senior care respite for caregivers senior citizen care senior companion care(The following is based on information from a printed article prepared by the Robert Wood Johnson Foundation.)

Did you know that, according to the Center for Medicare and Medicaid, nearly one in five older patients (2.6 million people) covered by Medicare is readmitted to the hospital within a month of discharge?

Did you know that more than a third of people do not get the tests, referrals or follow up care needed after a hospital stay?

Did you know that each year millions of potentially preventable trips to the hospital add billions to the nation’s health care spending?

Most people can’t wait to get home from a hospital stay and will promise anything just to get the physician to write a discharge order.  Although leaving the hospital sounds simple, all too often people find themselves back in the hospital within only a few weeks.  This is especially true of our elderly population.


Why does this happen?  Here are a few reasons:

1.  Medications get confusing.  Maybe they are not clear about what medications they should take and when to take them.  They may not take the medications because they get sick or because they are confused about what to take.  They may simply not fill their new prescriptions because they have no way to get to the drug store.

2.   Important information about their condition and what transpired in the hospital may not make it from the hospital doctor to their primary care physician.

3.   They may have trouble scheduling a follow-up appointment at their clinic.  Or perhaps they have no way to get there, even if they are able to get it scheduled.

4.   Perhaps they have no one to help care for them at home so they don’t eat properly or get their medications at the proper times.  Maybe they have no food in the house.  Maybe their family members are not able to care for them at home, or maybe they don’t have any family members.

5.   Maybe they don’t receive the results of important lab tests, which may change their treatment plan or the medications they need to take.


affordable home care assisted home care at home caregivers care for older people companion home care disability home care elder care in Minnesota eldercare at home elderly home assistance respite for caregiversWhat can seniors do to avoid re-hospitalization?  As someone taking care of elderly parents, what steps should you be aware of to help them avoid re-hospitalization?

1.  Ask and Ask Again: Don’t be afraid to bother doctors, nurses, and pharmacists with questions and concerns.

2.  Say It Back: They should repeat the instructions they get in the hospital back to their doctors and nurses to make sure they understand them.

3.  Have a Discharge Plan: They should leave the hospital with a detailed written plan that includes a schedule of  follow-up appointments, a list of their medical problems, a list of their medications and when to take them, how long to take them, possible side effects, and for what they are taking them.

They should also have a list of any equipment they need once they return home. This could include a wheelchair, walker, raised toilet seat, or oxygen.  Try to make sure any changes to their home, such as grab bars in the bathroom, have been made or at least scheduled.  A social worker may be able to help with getting the equipment they need.

4.  Manage Their Medications: To avoid mix ups and duplications, doctors need to know all of the medications they were taking before they came to the hospital—prescription, over the counter, vitamins, and supplements.  Get clear oral and written instructions and have someone help them go over their medications once they get home.

5.  Keep Appointments: See their primary care doctor or specialist as directed after leaving the hospital.  Bring their discharge plan and medication list to their appointment.  If they don’t have a doctor or don’t know how to reach a specialist, have the hospital staff set them up with one before they leave. They can ask for a social worker to help make arrangements.

6.  Know What to Do if They Don’t Feel Well: Know the warning signs for their particular condition and what they will do if their symptoms worsen.  Ensure they have a plan for whom to call during the day, night, or on weekends.

Bottom line:  With better planning and communication, many return hospital visits can be avoided.

Julie Ellingson, LSW

May 1, 2013


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