CaraVita Hospital to Home Program

Going Home

written by Dana Herron

Being in the hospital can be a pretty uncomfortable—and possibly even frightening—experience. Going home from the hospital can be equally frightening and uncomfortable, especially for older loved ones. Think about it. An illness requiring hospitalization has likely left the patient weak, and after surviving being poked and prodded and having tests or procedures, the patient must endure an often confusing and overwhelming hospital discharge process complete with hard-to-understand instructions. And all the patient wants to do is return to the comfort of home.

Having a good support system in place for the return home can be the difference between a successful outcome and being re-admitted to the hospital within a few days. No one wants to go back to the hospital, but the odds of being admitted again increase dramatically for older patients who are at greater risk for complications and lack of compliance with discharge orders. Hospital readmissions not only increase a senior’s risk for adverse effects, but hospital readmissions also cost us billions in health care spending each year. Studies suggest the preventable hospital readmission costs to Medicare tops about $17 billion per year.

The best line of defense against returning to the hospital begins before the patient goes home. Every patient needs an advocate who can meet with the hospital’s discharge planner to develop a good plan of care to meet the patient’s needs, including obtaining any additional health care services or equipment and getting an accurate, updated medication list. The patient’s advocate should have a clear understanding of any follow-up items, medication management, and what to expect when the patient is home.

Just how important is having an advocate? It’s essential. Patients immediately forget between 40% and 80% of the medical information they receive when being discharged. About half of the information they do remember is actually incorrect.

Once a patient returns home, here are the top 10 ways to help an aging loved one recuperate while reducing the risk of returning to the hospital:

  1. Start with a brutally honest awareness of the patient’s physical and cognitive limitations that may affect recuperation, and ensure that the patient is in an environment best suited for her current needs.
  2. Make sure the patient has nutritious foods and that he is getting plenty of fluids. Proper nutrition and hydration have positive effects, including keeping skin healthy and boosting the immune system.
  3. Help the patient manage all medications by taking the right medication at the right time and in the right way (for instance, with or without food). Older patients who are taking multiple medications may find it confusing to manage everything on their own.
  4. Assist the patient with performing exercises prescribed by home health therapists or other health care providers to increase strength, stamina, balance, and gait.
  5. Schedule appropriate follow-up appointments with physicians. All health care providers need to be updated regarding any changes in health status or medications since the hospital stay. See our recent article to read more about how a primary care doctor can help manage your care.
  6. Ensure transportation to follow-up appointments is available, and be sure the patient keeps these appointments by making it easy for him to get there.
  7. Make sure someone is available to help frail patients who need assistance in transferring to and from chairs, beds, and the toilet. An older person is more likely to fall if weak after a hospital stay or if new medication has side effects such as dizziness.
  8. Assess the patient’s home to remove any risk factors such as clutter or throw rugs that might make using a walker or wheelchair—or even walking—more hazardous.
  9. Monitor vital signs and any symptoms that might indicate a problem (swelling and difficulty breathing, for instance).
  10. Give the patient encouragement and a positive attitude to keep her motivated, and address any fears or concerns she may have.
CaraVita Hospital to Home

Sound easy? CaraVita Home Care knows how difficult it can be for family members to provide this type of high-level care and monitoring for their loved ones. Family members who are working full time or who don’t live nearby may not be able to fill this role by themselves, and that’s why CaraVita developed our Hospital to Home program.

Our program provides professional caregivers and nursing oversight to work with family members in putting all the important pieces in place as a loved one is discharged from the hospital. Our team approach includes the services of a licensed social worker, physical and occupational therapists, and nurses dedicated to ensuring the patient has an optimal recovery plan in place. We can also customize a care plan to suit the patient’s personal needs, schedule, and budget. More than just the physical care we provide, CaraVita’s Hospital to Home program gives our clients and their families peace of mind. As one client told us, “CaraVita Home Care’s services have relieved a lot of stress from me,” and that’s the promise behind our motto: Our Loving Care in Your Loving Home.

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