By Patty Aiken, Owner of Home Instead Senior Care in Guilford County

Mom goes into the hospital for a bout with pneumonia. In addition to the pneumonia, she has difficulty getting around because of her arthritis. The hospital staff is able to get her well enough to return home. Friends are able to help her out initially, but she convinces them that she is doing okay because she does not want to be a burden. However, she just does not eat properly or drink enough fluids. She forgets to take her medications, and she does not follow her prescribed exercise routine to gain strength because of her arthritis flare-ups. Her family members live out-of-town, making it difficult to oversee her recuperation. Initially, she is fine, but a family member comes to visit and notices that she is not getting stronger and seems frail. Subsequently, she has another bout with pneumonia, putting her back in the hospital for another stay.

This scenario is not uncommon. Are you as a family member (daughter, son, spouse) concerned that your loved one may return to the hospital shortly after discharge when you thought all was going well? Your concerns are very real.

Now, our healthcare systems are taking action to help reduce these types of situations. As of last October 1, our healthcare providers have more incentive to aggressively participate in the recuperation process to realize positive outcomes. These incentives are fueled by the penalties imposed by The Centers for Medicare and Medicaid Services (CMS) on healthcare providers for certain types of “avoidable” readmissions that occur within 30 days of discharge. Everyone involved with the patient (including the patient!) must seriously participate in making the recovery process successful. With positive outcomes, everyone wins. So, let’s take a look at the most common health problems associated with return admissions and what can be done to help avoid another hospital stay.

Some of the conditions which have shown the highest occurrence of readmissions are as follows:

Congestive Heart Failure
Acute Myocardial Infarction (Heart Attack)
Pneumonia
Arthritis
Diabetes
Co-morbidity (or multiple conditions)

The most important step in proper recuperation is to develop, with the participation of healthcare providers, caregivers and the patient, an appropriate and coordinated plan upon discharge. With a well-designed plan, the patient stands a much better chance of not returning to the hospital for another stay. Reading the main areas below that are the root causes of most readmissions, you can clearly see that these problems can be avoided by developing a simple, common sense plan. However, if someone is unable to help themself, taking care of these needs becomes problematic and often results in a negative outcome if they are not addressed. According to CMS, a patient’s failure to pay attention to the following areas result in most readmissions:

Medication management/compliance
Failure to make/keep/follow doctor appointments
Nutrition management
Follow-up on warning signs that may lead to another visit
Safety issues in the home

Taking a serious interest in managing the recuperation process is essential to avoiding another stay in the hospital. At times, family members are just not available for all of the time needed to assist their family member when they return home. On these occasions, Home Care can be an alternative solution that can serve as an extension of the family.

In many cases, skilled nursing care will not be required for all of the recuperative time. An experienced and qualified Home Care agency can assist the patient, the family, and the healthcare providers in achieving positive outcomes. Caregivers can help with proper meal preparation, make sure the patient gets to their follow-up appointments and medications are being taken at the appropriate times, notice warning signs for reoccurrence of problems, and maintain a safe environment for a speedy recovery. In the end, everyone benefits from proper coordination of care.

If you find yourself in this type of situation, think about soliciting the help of others in coordinating a plan of care that is going to yield a positive outcome. Be proactive. You will find that the resources available to you in your community are ready, willing and able to help and can work within a budget that is reasonable, considering the cost of returning for another stay.