In-Home Care Eases Hospital-to-Home Transitions for Seniors

Hospital stays, whether short term or long term, can cause stress and anxiety for seniors and family caregivers alike. While the entire family is eager for a loved one to return home, recover and resume their normal routines, many do not anticipate the difficulties that can come with transitions between care settings.

Navigating Hospital Discharges and Preventing Hospital Readmissions

The complications that can arise from care transitions are multifaceted and contribute to what has come to be known as the “revolving door” of hospital readmissions. According to research conducted by the Centers for Medicare and Medicaid Services (CMS), nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of more than $26 billion every year. Looking past the financial impact, hospitalization often takes a serious physical and mental toll on elderly patients even though they are admitted to improve their health.

Many readmissions are preventable and can be avoided with the addition of increased patient and family caregiver education, improved communication, better discharge planning, and proper post-hospitalization care. Hospitals, CMS and the U.S. Department of Health and Human Services (HHS) are working diligently to reduce rehospitalization rates, but seniors and their caregivers can take steps on their own to reduce the risks of readmission as well.

Professional in-home care can play an important supporting role in transitions between care settings.

The Benefits of Hiring Post-Hospital In-Home Care

Each patient has specific needs following a surgery or hospital stay, but in-home care offers several core services that can facilitate the recovery process, improve quality of life and ensure compliance with discharge instructions. This added support also alleviates pressure on family caregivers.

Better Communication and Care Coordination

Clear communication is crucial for coordinating care among multiple health care providers and across different settings. Without regular communication, there is no way of ensuring that a senior gets the care they need both in the hospital and after they have been discharged.

It is very important for patients and family caregivers to ask specific questions and request explanations of terms and concepts they are unfamiliar with to fully understand all conditions, treatments and post-discharge instructions. Hiring a professional clinician early on before a senior has even been discharged provides an added layer of knowledge and experience that can facilitate the discharge planning process.

Professional clinicians can be invaluable when it comes to learning about a client’s health issues, ensuring that the prescribed course of treatment is followed, and determining what services and assistance will be necessary to help them resume their normal routines.

Keep in mind the importance of discharge planning. While many patients are understandably eager to leave the hospital and return home, rushing through this process can increase the risk of missing important points and result in fragmented instructions for post-acute care.

Improved Adherence to Discharge Instructions

Medications are often changed or added to a senior’s regimen following a hospital stay, and a home health aide can make sure these modifications are adhered to once they return home. In-home clinicians can pick up a senior’s prescriptions from the pharmacy, provide medication reminders and keep an eye out for new and worsening side effects. The same goes for discharge orders for bed-rest, getting up to walk around periodically, or performing therapeutic exercises and stretches.

Follow-up appointments with an elder’s primary care physician and even specialists are another key part of post-hospital care. A professional care aide can help schedule these appointments, provide transportation to and from visits, and take notes. In-home care providers will incorporate all of these directives into a personalized care plan to be followed by the patient, their professional caregiver(s) and their family members.

Help With Personal Care and Household Tasks

Research has shown that hospitalization is associated with declines in functional abilities, and seniors often return to their homes with unmet needs for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). One study found that unmet ADL need increases the risk for hospital readmission.

A senior’s new or worse functional disabilities and supportive resources (or lack thereof) may not be adequately addressed during the hospital discharge planning process. Fortunately, in-home care provides valuable support with ADLs and IADLs. Services can include light housekeeping to ensure a loved one is recovering in a clean and comfortable environment, meal preparation services to help them get the nutrition they need to heal quickly, and assistance with bathing, dressing, walking and transfers.

Supervision and Companionship

A smooth hospital-to-home transition requires multiple precautions and steps. Hiring an experienced aide will provide added supervision and monitoring that can prevent complications, detect changes in physical and mental health, and decrease the risk of rehospitalization. This added peace of mind is an undeniable perk for families, especially long-distance caregivers.

Additionally, in-home aides cultivate meaningful relationships with their clients. Loneliness and a lack of engagement are detrimental to a senior’s physical and mental health, especially in the wake of a medical setback. Patients may not be able to return to their normal routines immediately following a hospital stay, but professional clinicians provide valuable social interaction and are skilled at devising activities that meet a senior’s abilities and preferences. Even if home care services are only hired for a short time after a hospital stay, this experience can come in handy down the road, should a senior’s care needs increase, necessitating long-term home care.

Hiring Post-Hospital Home Care

Home care agencies can help fill the gaps between hospital-to-home care transitions for either short- or long-term periods, depending on a family’s specific needs. There may be some initial anxiety about hiring someone to help care for a loved one after a hospital stay, but an extra set of hands and eyes can lessen the risk of a return visit.

Depending on the level of care required, medically necessary home health care may be ordered upon discharge. If it is not, non-medical home care services can still provide valuable support for the whole family.

Once you have determined the kind of care your loved one requires, a thorough selection and interview process will help you find a home care company and caregivers that you both feel comfortable with. Delays in post-hospital care can increase the likelihood of readmission, so it is important to start your search in a timely fashion.

All these measures will help to ensure your loved one’s safety and well-being and minimize the pressure on you, their family caregiver.


Superior Senior Home Care offers a complimentary consultation with an advisor to help you determine your loved one’s home care needs. To schedule your free consultation, call 805.430.8767 or contact us online.

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