Reducing the Risk of Readmission

Posted on Jul 28, 2014

I was at a meeting of senior care professionals last week and the term Frequent Flyer was used by an individual. They were referring to the too often issue of our senior loved ones being on a cycle of admission – readmission to the hospital or rehabilitation. I am not a fan of the term, but the topic is one that should be discussed.

About one-?third of our casework is providing care after a hospital or rehabilitation stay. In many cases we are brought in after a problem arose that could have been prevented that resulted in a readmission. Several years ago, we created our Going Home Strong and Going Home Safe programs specifically to respond to these needs. Programs like ours (which are fairly unique in the Boston area) are helpful for our seniors and their families. These programs work extremely; however, they are not used as frequently as I would expect.

One reason, our families tell us, is that the role of home care services is not always well explained as a resource for managing risk and complexity once at home. I have asked those involved in the discharge process why; the most common reason is that our services are out-?of-?pocket versus a covered insurance, Medicare or Medicaid benefit. Many involved in the discharge process, prefer not to discuss out-?of-? pocket costs.

If you, a loved one or a friend are soon to be discharged to home, you should at least consider home care services to help ease the transition and reduce the risk of readmission. Consider the following:

One in five seniors is readmitted within 30 days after a hospital or rehabilitation stay.
The hospital or rehab is a completely controlled environment with round the clock medical staff for intervention. Schedules are fixed and the individual (patient) subscribes to the facility time-? table for all aspects: Therapy, Personal Care, Meal times, Dietary choices, medication compliance, etc. This is 168 hours (24*7) of structure.
Home is a “completely” uncontrolled environment in which the individual has control over the timetable and choices throughout the day.
The Home Health Agency (i.e. VNA) is providing therapeutic support – Occupational Therapy, Physical Therapy, Speech Therapy, possibly wound care or other nursing services. They MAY also be providing up to 2 hours of personal care in the form of two @ 1 hour visits by a home health aide for bathing. This, in most cases, adds up to about 4-?7 hours of intervention in the week.
The remaining 161+ hours are unstructured and possibly unsupported leaving things at risk like:
- Fall risk / Ambulation support (e.g. when getting up at night for continence needs)
- Nutrition (preparation and food selection)
- Medication compliance (time adherence and taking proper medication)
- Follow-?up medical visit compliance
- Bathing needs
- Continence care (this may drive fall risk.)
Needs change significantly in the first 3-?5 days and 5-?10 day windows.

Why is this important? In short, therapeutic support and home care support are different. Therapy provides continued supervision and monitoring for specific recovery goals. It does not provide support for Activities of Daily Living (ADLs) that Home Care provides such as bathing, continence care, ambulation support, medication reminders, ambulation support, etc. Home Care can provide full or part time support for all of these needs. This is the support that can prevent slips and falls at any time failure to thrive due to diet, incorrect medication, getting to the doctor and even therapy compliance for between therapy visits. Our loved ones do not typically fall when the therapist is at the home, but in the middle of the night trying to manage their continence care.

The good news is that the need usually decreases significantly over time. The first 3 to 5 days are the riskiest. Our Going Home Safe and Going Home Strong programs were created specifically to help manage this risk, in concert with the VNA services that are normally provided. It consists of three categories of support:

Getting the home prepared (Home Safety Check, Clean up)
Getting home (The aide accompanies the individual home to ensure safety in the transportation and ambulation)
Being safe and healthy at home (Full personal care, medication set up and reminders, meal planning and preparation)

An investment in significant support such as live in care or round the clock or overnight care during this 3-?5 day window can allow for our loved ones to come home and stabilize safely. It allows those providing care to see the daily patterns of need so we you can craft the right level of care on an ongoing level (if necessary) to keep them safe and on the path to recovery.

If you know anyone who may benefit from our Going Home programs, please have them call the office and ask for Pam or me. We are always willing to sit with our families and discuss the pattern of potential need and how to best manage the economics of care. Best wishes for a great summer and thank you again for choosing Senior Helpers Boston to serve your needs.