Home Care and Hospital Readmissions

Home Care and Hospital Readmissions

For many people, their fear is not dying but losing independence due to ill health or simply aging and loss of abilities. While hospitals are there to help the sick, they don’t want people being readmitted too frequently or too soon after a discharge.

Often getting good support back at home—whether from professionals or loved ones or both—can mean less likelihood of returning to the hospital for things like not taking medication properly or falling down.

Ultimately, it benefits both individuals and hospitals if people can successfully remain at home and healthy, living as independently—or interdependently--as they are able.

Meet Larry

Larry, 83, is very familiar with the types of major events that send a person to the hospital as he is living with diabetes, an aortic aneurism, and a pacemaker, plus he’s had both knees and a hip replaced.

He receives professional in home care at least four days a week for eight hours a day. Larry’s caregiver helps him get dressed and provides transportation to the grocery store, medical appointments and to see friends. In addition, the caregiver helps with laundry, meal preparation and medication reminders. Medication management includes an awareness of dietary restrictions, such as limiting vitamin K (this has clotting factors that can be extremely dangerous for someone like Larry living with aortic aneurysm) and encouraging healthy snacks.

When Larry goes to the doctor, the caregiver brings a record that she has kept of Larry’s blood pressure, pulse and weight daily.

“In general, she’s always after me. ‘How do I feel?’ She tries to stay with me constantly. I feel safe with her,” says Larry. “I’m at home and I want to be able to stay home instead of going to the hospital.”

This type of attention is part of keeping Larry out of the hospital. A bonus is that he has a companion to keep him from feeling lonely, which can happen with many older people.

“She’s got a good sense of humor and makes me laugh,” he says. “She’s a happy camper and that helps—she thinks the glass is half full, not half empty, she’s got that attitude.”

Meet Alice

At 81, Alice is living with dementia, high blood pressure and diabetes and as a result she is at high risk for falls and infections, such as a kidney infection that sent her to the hospital.

The support of her husband and professional in home care services are keeping her at home and out of the hospital for now. Her caregiver comes three hours a day three times a week—and she has been for years. Alice doesn’t need a skilled nurse, but someone who can help with bathing, cooking meals, light housekeeping, medication reminders, and transportation to medical appointments.

Alice spends time with a caregiver being encouraged to do her exercises, which helps with Alice’s diabetes and dizziness. The goal is to reduce Alice’s risk of falling again, which has led to hospitalizations for her in the past.

There are four main areas of concern to hospitals when it comes to readmissions, and home care agencies can help with all of them:

Fall prevention

Properly taking medications

Following post-discharge instructions

Going to follow-up doctor appointments

While Alice’s caregiver helps her, her husband can focus on his own well-being so that he too stays out of the hospital.

In home care can be beneficial in the short-term and the long-term depending on the condition of the individual, and help with keeping people out of the hospital.

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