Too often, rehospitalizations and other post-discharge problems happen due to endemic issues in care transitions, according to research from the Agency for Healthcare Research and Quality.
Initiatives such as the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess readmissions,and this month’s inaugural National Care Transitions Awareness Day, have been a driving force to put a spotlight on lowering preventable hospital readmission. But there are a number of best practices that can be taken by patients, providers and caregivers to ensure readmission only happens if it is absolutely necessary.
In a recent webinar hosted by the American Society on Aging, Lakelyn Hogan, strategic partnerships representative for Home Instead Senior Care, explored the topic of care coordination as it relates to older adults, who are particularly vulnerable immediately following hospital discharge.
Elderly patients, one of the largest groups of consumers of health care services, frequently have a unique set of requirements such as transportation limitations and lack of support, Hogan noted. These factors contribute to abnormally high preventable hospital readmission rates in elderly patients — of the 20 percent of Medicare beneficiaries readmitted within 30 days, 75 percent are preventable, according to the American Nurses Association.
In order to lower readmission rates in older patients, it’s essential to first understand the factors driving them. For providers, complicated discharge instructions and pressure to discharge too quickly can contribute to future readmission, Hogan said. For patients, it’s commonly limited support once home and lack of education about their illnesses that can lead to readmission.
Keeping these factors in mind, here are three tips to help reduce readmission rates for the older population:
1. Plan ahead for the transition — before leaving the hospital
Hogan said that when forming a transition plan, it’s wise to work with patients to create a discharge checklist. Patients and providers should consider factors such as the length of the hospital stay, the extent of the illness, limitations of the patient, medication, dietary concerns and follow-up care. In addition, Hogan also recommended considering finances, as well as any short- or long-term assistance that might be needed once discharged.
Hogan noted planning ahead to maintain health, keep up with medication, ensure a safe household environment and keep open lines of communication with family can reduce the likelihood of missing critical steps that could lead to readmission.
2. Prepare the home
It’s vital that the environment a patient is heading home to is ideal for recovery, Hogan said. Preparing the home before the patient arrives can go a long way toward preventing readmission.
Hogan recommended patients keep the home environment safe by completing frequent safety checks, such as checking the fridge for outdated or spoiled foods and removing clutter. Shopping for groceries upon return and preparing special low-sodium or liquid-only meals can also help patients maintain health and strength at home. Also, arranging deliveries of any necessary medical equipment beforehand can eliminate anxiety.
3. Keep open lines of communication
Once home, creating support systems of family, friends and visiting health care professionals allows patients to be open about their recovery progress and well-being, as well as support with the inevitable adjustment issues. Good communication also allows them to receive help with tasks that can cause stress such as bills, mail and other important health care documents.
If in-home assistance is not an option, Hogan stressed the importance of preparing and maintaining emergency and medical contact lists to ensure open lines of communication with health care providers, friends and family.