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Returning Home Post-Discharge Care

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According to the Medicare Payment Advisory Commission, nearly one in five Medicare patients discharged from hospitals today is readmitted within 30 days—often unnecessarily. The 18 percent of Medicare patients who wind up back in the hospital after 30 days account for $15 billion in spending.

Returning Home Services

The care one receives during the first 30 days at home after discharge from a hospital or other healthcare facility is vital to ensuring their long-term recovery. Often mistakes made in medications, missed follow-up medical appointments, poor nutrition and dehydration, and lack of safety preparation in the home are the issues that can lead to readmission. Preventing these problems and others are already tasks that Home Instead CAREGivers provide. In fact, a 2010 pilot program conducted for the Home Instead Senior Care® network found that seniors who received the network's home care services had a significantly reduced rate in the percentage of patients readmitted to the hospital: 11 percent versus the national average of 20 percent.

The key elements of the Home Instead Senior Care network's Returning Home Program that can be easily implemented by its CAREGivers include:

  • Discharge coordination and execution—which involves conducting an initial meeting with hospital discharge planning staff to develop a detailed plan of care and instructions that will be used by the CAREGiver.
  • Medication management—which involves organizing and tracking pills and other medications to make sure that they are taken as directed and to prevent adverse effects.
  • Follow-up physician visit assistance—which involves making sure the senior keeps track of and attends follow-up medical appointments including providing or arranging for transportation.
  • Nutrition management—which involves meal planning, shopping and preparation to ensure that seniors are getting wholesome healthy foods and plenty of hydration that will assist them with recovery.
  • Warning sign monitoring and notification—which involves CAREGivers becoming familiar with the warning signs and taking appropriate action in a timely manner.

Utilizing these Home Instead CAREGiver services as part of a returning home program can mean better recovery outcomes for seniors who have been discharged from a medical facility with fewer readmissions and savings in both dollars and stress for them and their loved ones.

Resources:

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