There are significant problems associated with the quality of transitional care for older adults moving from the hospital to home. In fact, about one out of every five seniors is readmitted to the hospital within 30 days of initially being discharged. Research shows that many hospital re-admissions could be prevented.
Home Instead Senior Care’s “returning home” program identifies and implements best practices to reduce readmission rates, improve the overall transitional-care process and develop resources to assist patients in better managing their conditions after discharge.
Home Instead Senior Care can:
- Furnish transportation from the hospital to home
- Provide transportation to doctors’ offices and follow-up treatments, and other essential locations
- Conduct initial home-safety evaluations and provide light-housekeeping to keep the home clean and safe
- Make recommendations regarding safety items and engage other supportive services, as needed
- Train CAREGivers to recognize “red flag” signs that might indicate problems with recovery
- Provide CAREgivers, clients and their families with educational materials specific to the client’s condition
- Make sure that medications are picked up from the pharmacy and recommend that the client has a medication-management system in place
- Stress the importance of making follow-up appointments with physicians and allied healthcare providers, and making those appointments, as needed
- Assist clients in complying with their healthcare providers’ recommendations
- Compare physician-recommended diets with the client’s actual diet, and with the food that is already in the home
- Prepare healthy meals and assist clients in the selection of healthy nutritional alternatives
- Teach clients about proper nutrition, appropriate food selection and meal preparation
- Assist clients with bathing, grooming (including oral hygiene), and/or dressing
- Help clients with toileting and provide support to patients with incontinence issues
- Help facilitate and encourage regular, ongoing communication between clients, families and significant others
- Regularly review hospital discharge instructions and educate clients and their families about these instructions
- Keep daily care-related records for each client to help ensure the provision of consistent, high-quality in-home care services throughout the post-discharge care period
- Make recommendations if it is determined that a long term care plan is needed
- Work directly with physicians, home-health and hospice professionals
- Work with physical therapists to educate CAREGivers on requisite patient therapies
- Encourage clients to comply with recommended exercise and therapy regimens, and assist as needed
Research shows that four core protocols are essential to achieving favorable results in a transitional-care program: a disciplined, consistent discharge process; close, regular cooperation and communication between/among participating organizations; a strong emphasis upon effective CAREGiver selection and training; and dedicated supervision of care delivery. We can help.
