How the right in-home care reduces hospital readmissions

Mrs. Dorothy Bologna was born in Manhattan in 1929, in a strong community where she says everybody helped everybody.

But by the time she needed help, she says, “There was nobody left.” Her family had all died or gone to college and moved to areas where they studied. So she moved to the Gainesville area eight years ago to be near her daughter.

All seemed to be going well until Bologna had a fall and ended up in the hospital. Her hospital stay was followed by a stay in Gainesville Rehab for several weeks.

She says they worked on her leg strength. “I wasn’t using them,” Bologna said. “They felt like jelly.”

Discharge orders and readmission

For many patients, the trip home from the hospital does not last long. According to the Federal Agency for Healthcare Research and Quality, for some common conditions treated in hospitals, as many as one in  patients is readmitted within 30 days of discharge. And according to the New England Journal of Medicine, as many as one in seven patients undergoing major surgeries are readmitted within 30 days. Roughly 80% of hospital readmissions are for patients 65 years of age and older.

Readmission takes a toll on patients, their families and hospitals. Readmission means that patients are sicker. Readmissions cost Medicare alone an estimated $17.5 billion a year. And with the Affordable Care Act, hospitals receive reduced federal funding based on readmission rates.

Dr. J. Douglas Wall, Vice President of Medical Affairs for Novant Health UVA Health System says, “While we don’t have specific statistics on how many people have to return to the hospital because they don’t/can’t follow the discharge orders, it is one of the most common reasons why patients are readmitted to the hospital. Patients sometimes do not understand the orders or don’t fully follow the instructions. They may be unable to carry out all elements of what their discharge follow-up needs to be, whether those are follow-up appointments, instructions, diet modifications, etc.”

Novant Health UVA Health Systems strives to reduce the amount of people who are readmitted to the hospital. That’s why they have been taking the simple but effective step of calling patients post-discharge to check on them. They ensure patients have made their follow-up appointments, see if they have taken their medications and if not, find out what is preventing them from doing so. They ask if there are barriers to obtaining the right medications, either physical or financial, and screen for those prior to patients leaving the hospital.

Wall says asking questions and getting patients to explain their own discharge orders prior to discharge is a “way of helping the patients to drive home with more than a piece of paper.” They aim to solicit their understanding of healthcare and staying well.

Wall says if a patient needs financial help, case managers can determine what type of assistance is available. In some cases, they recommend home health care.

When more is needed

Providers of home care, Home Instead Senior Care® in Manassas says about one out of every five seniors is readmitted to the hospital within 30 days of initially being discharged. A home care provider often can give the kind of assistance needed to ensure patients are following discharge orders by ensuring patients are taking their medications correctly, accompanying them to medical appointments, cooking them healthy meals and more. The results? Not only are patients healthier, they are less likely to be readmitted for the same reason.

Caregivers at Home Instead Senior Care® are not medical providers, but they are fully trained, bonded and insured. Through the practical care they offer, more seniors live at home instead of in nursing facilities and do not face hospital readmission.

In a study of seniors with congestive heart failure (CHF), a common diagnosis resulting in readmission, by providing home services to seniors in Henrico Doctors’ Hospital of Richmond, VA, Home Instead saw a 35-percent improvement upon the hospital’s overall CHF readmissions rate (16.9 percent); 59- and 58-percent improvements over those of its parent company (19.9 percent and 19.8 percent, respectively); and a 97-percent improvement upon national readmission estimates for Medicare enrollees with CHF (24.6 percent.)

Bologna uses caregivers from Home Instead Senior Care®. She says Home Instead has been wonderful to her. “I’m home with great care,” she says. “I’m very blessed.” If Bologna needs something delivered, like her special order walker with handbrakes, a seat and a basket, Home Instead makes sure she gets what she needs on time. Caregivers do light cleaning, offer entertainment and companionship and ensure she is following discharge orders. And caregivers are “great cooks,” Bologna says. “They know how to save leftovers.”

Toni Adams is one of Bologna’s caregivers. Bologna says, “She’s the kind of person who makes you feel better and likes it.”

“I love elderly people,” Adams says. If it’s not in your heart, you might as well not do it.”

What’s one of Bologna’s favorite things about her Home Instead caregivers? “They make you laugh,” she says. “And that’s the best medicine. It’s priceless.”

Bologna has not been readmitted for the same injuries and continues to improve.

This post is sponsored by Home Instead Senior Care of Manassas.