Preventing Hospital Readmissions

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For most of us, being sick enough to require a hospital stay is probably one of the most frightening experiences we will ever have. The unfamiliar surroundings, combined with the physical discomfort, pain and anxiety that naturally comes with being ill is enough to make even the strongest person weak in the knees. Unfortunately, for many older patients, they get to live and relive the experience far too often.

Approximately 20 percent, or one in five, of recently hospitalized Medicare patients are readmitted to the hospital within 30 days of discharge, reports a study published in an April 2009 issue of the New England Journal of Medicine. One in three is back within 90 days, and as many as 50 percent of patients are readmitted within the year. The reasons are multi-faceted, but the study concludes: These typically older men and women often don't understand how to care for themselves after being released, and even if they do, many lack the family and even medical support to do so adequately.

"Many patients don't want to be a burden to their families," says Linda O'Reilly, manager of Clinical Services for Palos Community Hospital's Home Health and Hospice Care, "and they also don't want to be the person who cries wolf. So when they do get symptoms, they wait and see. They often are in full-blown exacerbation of their disease by the time they get help." At that point, a return to the hospital is often the only solution.

There are numerous steps you and your loved ones can take to ensure that you both get the support necessary to prevent hospital readmission. These tips will help you recover more quickly in the comfort of your own home, and that in turn will improve not only your health but your independence.

Asking the Right Questions

One of the main reasons behind hospital readmissions is an overall lack of understanding of patient care instructions and how that care will be coordinated once the patient returns home. "There's a lot to resolve before a patient leaves the hospital," explains Maureen Fitzgibbons, director of Palos Community Hospital Home Health, "which can translate into a lot of information that can be difficult to coordinate, especially if it's coming from multiple doctors."

The discharge process should not start at discharge. As soon as you or your family member is hospitalized, it is time to start gathering the information necessary to make the transition home as smooth as possible. The best place to start is by asking the right questions about the care you'll need before you even leave the hospital.

The most important questions to consider are those about basic care. Can the patient perform the functions of daily life, such as bathing independently, dressing, preparing meals and eating? Can he or she safely walk without assistance? Can the patient drive a car to get to doctor's appointments? And is memory and mental alertness sufficient to coordinate these tasks?

Another concern is whether the patient is at risk for falls. "Falls are a major reason for hospital readmission," Fitzgibbons says. If there is a chance you or your loved might experience a fall associated with muscle weakness or some other physical concern, you should have a conference with the nurse and/or physician to discuss fall prevention, Fitzgibbons recommends. The bottom line when it comes to post-hospital care: Are you or your loved one safe at home if left alone?

Prescriptions are another critical area of concern for older patients leaving the hospital. "Minimally, they need to know what medications they are supposed to take and when to take them," O'Reilly says. "They also need to be able to reconcile the medications they were taking before they entered the hospital with any new ones they were prescribed." It is important to make sure the patient either has all of the medicines needed or has the ability to get them, and that there's a basic understanding of what each prescription is for and the potential side effects.

Questions about medications are a good place to start when talking to hospital staff about discharge instructions.

Asking the Right People

Another common problem that increases the risk of readmission is that patients don't always communicate the real story about their home environment and who will be able to care for them. "The situation may involve a married couple, and one of them is the patient," Fitzgibbons says. "Both are medically fragile, but because they don't want to be a burden, they are hesitant to ask for help from their sons or daughters who are in the middle of their own lives."

Besides your physicians and nurses, the third person you should consider talking to before leaving the hospital is someone from social services. A medical social worker can answer all of your questions that don't specifically relate to your illness, such as where to get necessary medical equipment, what support services are available in the community, and where you can turn for financial assistance. For some people, the very words "social worker" can have negative connotations, but when you or a loved one needs health care guidance, a medical social worker is a valuable resource that a hospital provides to all patients, without charge, even after you're discharged.

"Our role is to educate patients and families about all of the different services and options that are available to them," says Margaret Garbaciak, assistant director of Social Services at Palos Community Hospital. "We educate people about what Medicare, Medicaid and other insurances will cover. We discuss whether the patient could benefit from home health care or a temporary stay in a skilled nursing facility for rehabilitation."

If you need additional or more skilled help, home health care is another valuable resource for patients. Home health services include skilled nursing care, rehabilitation therapy, help with daily activities, nutrition counseling and even caregiver respite. Registered nurses, social workers and other home health staff work directly with physicians to provide the additional help you need so you can maintain independence for as long as possible.

"We can help families look more realistically at patient needs and help them find the assistance they require," Maureen Fitzgibbons says. Home Health services are medically comprehensive and include:

• Clinical monitoring
• Patient education
• Personal care
• Medical social worker support
• Nutrition and dietary counseling
• Intravenous therapy
• Medication and medical equipment coordination
• Speech, physical and occupational therapy
• Wound care
• Home telemonitoring for health failure patients
• Financial and community resource referrals

"Our Private Duty services can fulfill a lot of custodial needs, such as assistance with bathing, light housekeeping and even meal preparation," explains Fitzgibbons. "Primarily we teach families and patients how to stay as independent as possible, and help them navigate the medical system outside of the hospital."

Whether you're still in the hospital or already home, always make sure a family member or friend is with you when you talk to any medical personnel. When you're not feeling well, it can be difficult to make sense of the information you're given, and another person may think of questions that don't immediately come to mind. Also be sure to write down the information in a notebook, along with contact names and phone numbers, so you can refer back to it. If you take no other phone numbers home with you when you leave the hospital, make sure you get the ones for social services and a home health care agency.