Avoiding the revolving door

Steering clear of hospital re-admission

Steering clear of hospital re-admission

No one wants to spend time in a hospital. Unfortunately, for seniors the risk of re-admission after a hospital stay is greater than other age groups.

According to the federal government, between 12 and 20 percent of seniors with Medicare are re-admitted to the hospital within 30 days after an illness. Within 90 days, upwards of one-third of those patients are re-admitted.

To avoid re-admission, a patient’s aftercare when leaving the hospital should include a plan to maintain health. This is referred to as “discharge planning.” Patients who successfully follow the treatment and discharge plans will have a better chance of preventing recurrence of illness and preserving their health. This means communication among hospital caregivers and patients is key. Patients should also ask questions if they do not understand instructions.

According to Angie L. Banet, MSN, R.N., director of Care Management and Clinical Effectiveness at Norton Audubon Hospital, the discharge planning process begins with a visit from a care manager.

“The care manager is a nurse who specializes in discharge planning,” Banet said. “The care manager will help identify any needs that you have after discharge and help coordinate those needs with you.”

After discharge planning meetings, the hospital wants to be sure the patient has access to services, such as home health services or rehabilitation, and has made the best decisions about aftercare.

“We want to make sure that the patient is continuing on the right path to stay healthy and that they are following their physician’s plan of care,” Banet said. “It is so important for us to stress patient follow-up.”

Adhering to the discharge plan is often easier said than done. Some patients may find the process overwhelming, and that’s where it helps to have a family member or caregiver with the patient.

Banet said that before a patient is discharged, the hospital will ensure the patient and support people understand the discharge plan completely. Caregivers are included in the planning process and empowered to assist the patient with decisions. If a patient needs additional care after leaving, the hospital will make sure the patient and caregivers are clear on how to contact those agencies.

“The caregiver of a patient should be involved in the decision-making on what’s right for the patient,” Banet said. “However, it’s ultimately the patient’s choice.

“With that being said, we try to provide patients with knowledge to make educated decisions. For instance, if an outpatient rehabilitation facility specializes in orthopedics or has a support group for COPD, we want the caregiver to help the patient make an informed decision about the right care or services that are needed.”

When necessary, the care manager in charge of the patient’s discharge will reach out to other clinical and therapeutic staff to ensure the patient has a seamless transition when leaving the hospital.

More than anything, Banet wants patients to know that she and her staff can help.

“We’re here to collaborate and work with your family in providing the best care possible,” she said.

Did you know … the affordable care act is changing the way hospitals view patient care.

Health care reform now rewards hospitals for the quality of the care they provide (rather than the quantity, or number of patients they care for). Patients with Medicare are in a unique position to influence these changes. Medicare penalizes hospitals with high rates of re-admission and hospital-acquired infections. As a result, hospitals are working even more diligently to improve patient safety protocols and the aftercare and discharge planning they provide. Patient surveys are used to tell Medicare how hospitals are doing, as well as let hospitals know where they are succeeding and where changes may be needed. If you receive a survey after a hospital stay, you should answer it honestly — it’s your chance to have a direct voice in your care.


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