How to Reduce Hospital Readmissions and Keep Aging Loved Ones at Home

Hospital readmissions are frustrating. Your medical team, family caregivers (and you!) work tirelessly to improve your health so that you can return home. But within 14-30 days, one out of five patients is readmitted to the hospital.

It feels pointless! Why work so hard to make sure a patient is ready for discharge when they will be back in less than a month?

Returning to the hospital shortly after discharge:

• Costs taxpayers over $17 billion per year
• Increases the patient’s risk for infection
• Intensifies delirium
• Leads to more falls, bed sores and muscle weakness
• Causes rapid physical and mental deterioration in aging adults

It’s not a pretty picture. That’s why transitioning elders back into their homes with proper support and assistance is vital to their health and independence.
Researchers have studied the causes of hospital readmission. You can use these evidence-based strategies to ensure a smooth transition home from the hospital so people who return home can stay there. Case managers or discharge planners play a vital role in this process.

Why Case Managers Help Prevent Hospital Readmissions

Case managers are professionals who speak for the patients and work as the bridge between patients, their families and healthcare professionals. Their job is to look at the complex health needs of each individual and help map out a plan to address those needs.

Not an easy job! Case managers are like jugglers. They take all the care aspects of a patient and work to keep them all up in the air.

Case managers...

• Help the patient while admitted to the hospital.
• Work with physicians, nurses, social workers and other professionals to provide for the current or even future needs of patients.
• Arrange for long-term care or home care on discharge.
• Address ethical, insurance and legal issues.

The role of the case manager is essential to the success of keeping patients from returning to the hospital. A case manager’s reach goes beyond the hospital and can extend to the community partners working with the patient at home.
Research shows that a case manager’s role in teaching the patient about what to expect when they return home will have a positive impact on their health. Returning home is often disorienting and upsetting for patients, as well as stressful for family members. Bridging care from the hospital to home is key to ensuring a happy return home.

What to Do Before You Leave the Hospital:

Going back home can be hard for patients. As much as you might want to leave the hospital, it can be overwhelming to go from a place where others are taking care of you to managing on your own.

Someone might have fears like:

• “What if I am not strong enough to be at home on my own?”
• “Who will take care of me?”
• “I don’t know what to do!”

Answering these questions will prepare the patient to be successful in staying out of the hospital. You can accomplish this through five basic steps.

1. Partner with a home care provider. A referral to home should ideally be followed by a professional caregiver visit the day after discharge. This is the scariest time for the patient and when they most need reassurance and reminders of the hospital to home care plan. A study in 2014 found that a home visit within three days of hospital discharge was the most effective way to reduce readmission.
   
2. Read patient discharge education. When you aren’t sure how to stay out of the hospital, you are more likely to end up back in the hospital! Education on disease symptoms, diet, lifestyle changes, medications and follow up appointments empower the patient and the family to take responsibility.
   
3. Assess the family’s caregiving ability. Family caregivers are not always able to care for the patient. But when family is included in discharge planning there is a decreased rate of readmission. Family caregivers are also at a high risk themselves for depression and caregiver burnout.
   
4. Regular contact with the patient after discharge. Post-discharge follow-ups by a professional caregiver or home health aide allows for reinforcement of education, monitoring symptoms and assessing progress or adjusting care as needed. This strategy was shown to reduce returns to the hospital by 17% in those 65 and older.
   

5. Arrange doctor visits in the community. Fewer than half of patients will see their community doctor within two weeks of discharge.

   A Yale-led study found the following strategies were most likely to reduce the patient’s return to hospital:
   

   1. Working with community physicians.
   2. Having follow up appointments already made.
   3. Having a process in place to communicate discharge summaries.

   Patients want to stay home. Staying at home promotes better health and can save thousands of dollars in health care costs. People just need the right support and education to transition back home.

How to Ensure the Hospital to Home Transition is as Smooth as Possible

There is a three-day window of opportunity that sets the patient up for a successful transition from hospital to home. If you miss that window, the patient has a one in five chance of being back in the hospital within 30 days. The homebound patient is often scared and confused.

Sometimes a person will try to keep up with what they did prior to their hospitalization and end up hurting themselves, or they will feel weak and helpless. A good strategy and proper support can ease this transition time and help the patient to feel confident at home again.

Once a patient is released from a hospital, the goal should be to prevent their return. Hospital readmissions are not good for patients and cost millions. Case managers, doctor follow-ups and well-trained caregivers are the most important pieces to the puzzle that can help prevent patients from returning too soon.

A patient that goes home with proper support and has a smooth transition from the hospital is a patient who stays safely at home.

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