While one is usually anxious and happy to leave the hospital for home, flaws in the discharge process can lead to a quick return. Some statistics that might surprise you: 5% of Medicare recipients are readmitted in to the hospital within 5 days of discharge; 20% are readmitted within 30 days; by 90 days the % rises to about 35%.

Some of the primary reasons for readmission include poor communication with physicians and other members of the patient’s care team, conflicting or misunderstanding medical information/instructions, missed doctor’s appointments and medication errors. A fragmented process and communication issues account for most of the preventable incidents, which disproportionately affect older adults and those with multiple conditions. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Family caregivers may be ill prepared for increased eldercare needs of an elder loved one weakened by a hospital stay and illness.

Those at highest risk of readmission are patients:
• With heart failure, COPD, psychoses, intestinal problems, and/or who have had various types of surgery (cardiac, joint replacement, or bariatric procedures).
• Taking 6 or more medications, who have Depression or poor cognitive function, or have been hospitalized in prior 6 months.
• Who are discharged on weekends or holidays.

Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. One study indicated that patients who lived alone and did not receive home care services were twice as likely to be readmitted as those who received in-home care services.

In the Medicare Care Transitions Act of 2009, the federal government mandated reduction in hospital readmissions with better care coordination and follow up services, such as home health care.

EasyLiving can help with our Transitions of Care Program. Contact us or read more about our 1st 24 hours homecare program-helping with Pinellas County home care needs during this vital period after discharge.

Look for our upcoming article on specific questions to ask and a checklist for post-hospital needs, as well as more information on how our Clearwater home health services can help bridge the gap.