A common misconception when your loved one is discharged from the hospital is that, since they feel well or are well enough to return to daily activities, they are able to take care of themselves. The reality is that the transition from the hospital back to the home is an extremely critical time, especially for patients who cope with multiple chronic conditions like COPD, CHF, diabetes and dementia. According to a 2009 national study in the New England Journal of Medicine, 20% of all Medicare patients are readmitted to hospitals within 30 days of discharge and 33% are readmitted within 90 days. While there are many reasons why so many newly-discharged seniors return to the hospital, many of the contributing factors can be addressed and avoided. Extending care from the hospital to the home through home health care can significantly reduce the chance of your loved one returning to the hospital.
Advocating for your loved one.
In many cases, when your loved one is discharged from the hospital back to the home, skilled home health care services are prescribed. Typically, this service is arranged by hospital discharge planners. However, a prescription for home care is not an automatic part of the hospital discharge process.
As an involved advocate who knows your loved one and his or her home situation best, ask yourself these questions. Does your loved one:
- Live at home with limited or no community support
- Require assistance with taking medications when and how they are prescribed
- Take more than 7 medications
- Have a history of mental illness
- Often have difficulty understanding or following directions from the doctor
- Requires assistance with daily activities like bathing, dressing or grooming
- Have dementia, Alzheimer’s or other cognitive challenges
- Live with CHF, COPD or Parkinson’s
- Struggle with incontinence
- Suffer from an acute/chronic wound or pressure ulcer
- Have trouble moving around safely, or have a history of falls
- Frequently end up back in the hospital or ER
- Require assistance in management of oxygen and/or nebulizer
If you answered “yes” to two or more of these questions and home health care has not yet been mentioned by the hospital discharge planner or physician, you can be proactive and use your “red flag” questions to start the discussion. It is important that you and your loved one have the necessary support to keep improving once out of the hospital and back in the “real world,” so don’t be afraid to be vocal and ask questions. A tip: taking notes during any discussions with the physician or discharge planner may be especially helpful, as it can be hard to keep track of details in the often stressful, confusing or overwhelming hospital setting and discussions may need to be shared with other family members and caregivers after the fact.
When considering the option of home health care, keep in mind that you have the right to choose which company is the best fit. View our patient guide to learn more about home health care and to see questions the Centers of Medicare and Medicaid Services recommend you consider when making this decision.