As owner of Senior Helpers Boston and South Shore, I am fully aware of the statistics following patients who return home from acute care. The harsh reality is that 1 out of 5 seniors return, within 30 days. It is one of the most troubling issues crippling our healthcare system in general, and for families, can prove devastating. Why does this happen? Where and how do things go so terribly wrong?

There are a couple of big reasons. For one, patients leaving a hospital or skilled nursing facility are leaving, in effect, a very “controlled” environment. Virtually everything is being done for them and they have few, if any decisions to make about taking medications, getting physical therapy, or eating. In going home, they are returning to an uncontrolled situation, where suddenly they find themselves on their own and in charge of every decision requiring attention.

Secondly, the discharge process, like most events in today’s healthcare system, is chaotic and difficult to personalize. Too often social workers are over-burdened and have little opportunity to get to know individual patients and families, let alone their special requirements. They are on tight deadlines to discharge multiple patients, and many automatically turn to “go-to” resources for standard follow-up care. As a result, seniors are often sent home overwhelmed. They have sheets of instructions but too little preparation. And even fewer tools to navigate through the information they are given.

What can happen in the first day or two at home can sabotage the best of recovery efforts. A fall. A missed medication. Dehydration or simply forgetting to eat. Family members are often at a loss as to how to help. And seniors, many of them proud and independent, are too embarrassed to ask for it. How often I hear, “Oh, I’m just fine,” when in fact, they are far from it.

So many of these stories do not have happy endings. There are frantic calls. Panicked visits from adult children. Or worse, 911 and a trip to the Emergency Room.

Demand for Better Outcomes

Over the past 48 months I have been working closely with every part of our healthcare community to isolate and understand the components for better recovery care. My exploration has included discussions with hospital leadership, frontline discharge planners and social workers, skilled nursing facilities and other acute care providers.

While you and I call this “recovery care”, the industry broadly refers to this larger issue as “re-admission management”, and a lot of experts in the industry are studying its impact on seniors, and the cost of delivering healthcare.

I have reviewed the challenges of readmission management with managed care and policy expert Josh Luke, who has a keen understanding of what is at stake, and the rights of patients in the center of the discussion. If anything, Josh is considered a “disrupter”, as he advocates for the patient’s right to choose between going home or going to post-acute care, and lobbying for more experimentation of new programs that might be a bridge-care option. 

The Call for a New Paradigm In Recovery Care

The thinking and work of these professionals are significant influences to a major program currently designed by Senior Helpers Boston that will dramatically impact recovery care across our healthcare continuum. We are anxious to roll it out in the spring of 2017 and it will impact the success rate of home transitions.  More importantly it will be a major tool for you in managing your own readmission risk.

But we are impatient because we see the impact of readmission on the families we care for and we know we can help.

The Art & Science of Blending Expertise, Environment, Empowerment, & Engagement

When it comes to rooting for families and loved ones who want nothing more than to recover safely at home, then it becomes my job, and that of my nurse case managers and caregivers at Senior Helpers, to provide the support and expertise for our new paradigm in “Going Home Safe”.

And this is exactly what we have done.

I believe we must change the rules about recovering at home. We must simplify the jargon for families and loved ones and empower them with information they can use and tools and processes that enable them as well as the health care providers to succeed; not put away in a drawer.

We know that non-medical support can make an overwhelming impact on readmission risks. But we must do more to help our seniors Go Home Safe. Do more to mitigate the risk of a return to acute care. And more to support their full recovery to wellness.

Going Home Safe: Comprehensive, not Complicated.

The program we have innovated and introduced is built on a well-designed discharge plan, effective nurse Case Management, caregiver training and specialized care provision. It has built-in contingency planning if risks materialize, and involves collaboration with you, the family, and your system of care providers.  It has been a long process to formulate and prepare, and we are ready to support your needs for recovery care, simply, and effectively.  We guarantee it.

Think of “Going Home Safe” as A New Beginning

In our dynamic “Going Home Safe” transition program, our accountability and coordination of support is spelled out in a complete plan prior to discharge. It is backed by the Senior Helpers Guarantee.

We immediately work to ensure “home” is physically safe for the loved one, as well as fully prepared for the arrival of a senior eager to be on the road to full recovery. It is replicating the “controlled” environment I mentioned. We assure loved ones and families that all is in place; discharge orders and diet plans are being followed, medications are being taken, and the house is properly equipped. 

Trained and certified specifically in our “Going Home Safe” program, our nurse case managers and caregivers have the skills, and provide the experience and expertise to family members and loved ones in this critical transition. Our formal “Going Home Safe” Workbook helps families prior to discharge. Families can choose specific programs of care from an extensive suite of services, based on determined risk profiles, so we can then support the recovery process from 3 to 30 days or provide long term ongoing support.  

“Going Home Safe”, and being able to stay on a path to full wellness at home, is a huge deal. It’s an important program we offer at Senior Helpers Boston and South Shore. But “Going Home Safe” is bigger than that. It is a portal to two visions we have for serving seniors. The first, is to deliver care and comfort on your terms, in your homes, with all the respect and empowerment you deserve. The second, is to make the healthcare system work better for you. More effectively, efficiently, carefully, and care-ingly. 

If we can have this kind of impact with “Going Home Safe”, it’s a very good day.




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