Post-Hospital Care for Elderly Veterans: How to Avoid Readmission and Support a Full Recovery
With advancing age, seniors’ chance of hospitalization rises due to common chronic conditions and household accidents. Post-hospital care for elderly patients — especially veterans — is a vital part of their recovery process, and the right plan can mean the difference between a full recovery and a costly return to the hospital.
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-discharge care plan for seniors, 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 Hospital Readmission Happens and Why it Matters for Seniors.
By definition, hospital readmission occurs within 30 days of a patient’s original discharge. 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 readmission 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 Post-Hospital Care for Elderly Patients Looks 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.
Medical and Rehabilitative 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
- Telehealth monitoring and follow-up consultations
Personal and Supportive Care
Other care services commonly provided after discharge 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 Things to Do Before Your Loved One Leaves the Hospital
- Before discharge from the hospital, ensure you have all prescriptions and instructions for medications (see our tips for medication safety and routines). 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. See our full guide to home modifications for seniors aging in place for room-by-room safety tips.
- Investigate your loved one’s options for home care. If they are a veteran or surviving spouse of a veteran, they may qualify for the VA Aid and Attendance benefit, which can cover the cost of home-based care after discharge. Learn more about Aid and Attendance 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 the Right Post-Discharge Care Provider for Seniors
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 needs may be more complex.
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 and home care are related but distinct services — understanding the difference can help you choose the right level of support. That said, if health needs are extensive, a skilled nursing facility or other residential option with 24-hour assistance may be more appropriate.
When evaluating providers, consider asking: How quickly can care begin? Are caregivers trained in post-hospital recovery support? What is covered by Medicare, Medicaid, or VA benefits?
Speak to your loved one's physician and discharge team about their recommendations and any relevant resources. You can also use reliable online reviews to vet providers. Many hospitals have social workers on staff who can help direct you to coverage options and community resources.
Tip: If your loved one is a veteran, ask specifically whether the facility or home care provider has experience working with VA benefits — this can significantly impact which costs are covered and how quickly care can begin.
Support Your Veteran's Recovery at Home With the VetAssist® Program
Post-hospital care is a crucial part of a full recovery and better long-term health outcomes. The decisions made in the days and weeks following discharge — about home safety, medications, follow-up appointments, and the right level of care support — have a lasting impact on whether your loved one truly recovers or faces a setback.
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.
