Post-Hospital Care and How Best to Avoid Readmission
With advancing age, seniors’ chance of hospitalization rises due to common chronic conditions and household accidents. Post-hospital care for elderly patients is a vital part of their recovery process.
While hospital staff will stabilize a patient before discharge, their recovery is not over, and the first days and weeks at home have a major impact on their full rehabilitation. A post-hospitalization care plan and related resources should be vetted before a crisis situation arises to ensure your loved one’s needs are met and hospital readmission is avoided.
Why Does Readmission Happen?
By definition, hospital readmission occurs within 30 days of a patient’s original discharge. (Read more here.) Readmission is undesirable for patients and their families, who want to see steady improvement and a return to health. It is also undesirable for hospitals, which may already have their staff and occupancy overextended and which often cannot bill Medicare and Medicaid in these cases. Everyone involved in a readmission would rather not see it happen.
So why does it happen?
While some cases of readmission happen because a patient was discharged too early, it is more common that there was insufficient short-term care for post-surgery, not enough communication with discharge planning, or inadequately personalized care. An elderly patient’s transition from the hospital should be to short-term care of some kind, whether home-based or in a specialized facility. To underestimate the value of post-hospital care is to increase the risk of health complications and hospital readmission.
What Does After-Hospital Care for the Elderly Look Like?
Post-hospital recovery can include home-based care services provided by professional caregivers and/or nurses. It may also include a short-term stay at a nursing home or skilled nurse facility. For many, there is some telehealth involved as well as in-person care.
Depending on your loved one’s condition and needs, common healthcare provided includes, but is not limited to:
- Medication management and/or administration
- IV therapy
- Wound care
- Pain management
- Physical therapy
Other care provided might include:
- Mental health or moral support for the patient and sometimes their family caregiver(s)
- Education on health-supporting nutrition (or meal services)
- Assistance with ADLs
- Speech therapy, especially after a stroke
- Occupational therapy
- Consultation on assistive devices for walking
Five Considerations Before Leaving the Hospital
- Before discharge from the hospital, ensure you have all prescriptions and instructions for medications (see our tips for medication safety and routines here). Make it easy for your loved one to take their prescriptions as directed.
- Know the plan for post-hospitalization communication and appointments. Follow-ups should be scheduled and on a calendar, with transportation planned ahead.
- If your loved one is going home, do a detailed sweep of their home for tripping hazards, items on high shelves, and dark living spaces where accidents may happen. An occupational therapist is a wonderful resource for identifying and mitigating risk, as well as helping simplify daily routines.
- Investigate your loved one’s options for home care. If they are a veteran or a spouse of a veteran (living or deceased), they may qualify for the VA’s Aid and Attendance benefit, which covers home-based care (more here). This will ensure they have help with daily activities during their recovery and have a care professional monitoring their progress—or catching complications early.
- Plan to check in with your loved one frequently after their hospital stay. Hospitalization leaves many feeling vulnerable, and being alone can lead to low spirits. Keep your loved one from feeling forgotten by calling, texting, or visiting often.
How to Choose Post-Hospital Care Providers
Beyond required or prescribed resources, consider what you and your family can realistically provide to your elderly loved one as they rehabilitate. If your loved one has memory or cognitive issues, mobility challenges, or other chronic health conditions, think about how their post-hospital care might be impacted.
Home-based care is often preferable for elderly patients, as they can be in familiar surroundings and find comfort in their belongings and routines after their hospital stay. Increasing numbers of seniors are choosing to age in place rather than move to assisted living. Home health is available in addition to home care (here is the difference). That said, if their health needs are extensive, you may want to consider a skilled nursing facility or other residential option where they can access 24-hour assistance.
Speak to your loved one’s physician and staff about their recommendations and any information they can provide, like websites or brochures. You can also use reliable online reviews to vet providers. Find out what is covered by your elderly loved one’s health care plan, as well, and calculate costs for the different options available. Many hospitals have staff, including social workers, who can help direct you to the right information regarding coverage and community resources.
Post-hospital care is a crucial part of a full recovery and better health outcomes. If your loved one needs home care, our VetAssist mission is to make home care easily and quickly accessible for those who qualify through the VA Pension with Aid and Attendance benefit. Veterans Home Care can help you determine whether you or your loved one will be eligible to receive the benefit, which can cover some or all of the cost of home care, and we make it easy to apply. Chat with us via our website, or call us at (888) 314-6075.
