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.

Here is a checklist of things to consider and ask about to ensure a safe return home for you or someone you love:

Specific, clear follow up care instructions in lay terms. Ask to have things explained, and preferably have a family member, friend or geriatric care manager with you to listen as well. These should include: your diagnoses and reason for the hospitalization, all medications with instructions, follow-up appointments, any therapy or treatment you will be receiving (and who will be providing it, when will it occur, how can you reach them).

How you are functioning currently and your strength level. Are you in a weakened state or will you be on medications that make you drowsy? If so, you may need extra help with home care tasks and someone with you to ensure safety.

Signs or symptoms you should be monitoring. Should you be watching for certain things that may indicate an infection or threat? What should you do/who should you call if you notice this sign or symptom?

Will you receive Medicare home health services or in-home rehabilitation? When will those services begin and how long can you expect them to continue?

How will you get medical equipment or medications you need immediately?

How will you get safely home on the day of discharge? (Consider again your functional state and strength.)

Physical therapy and skilled nursing services in the home are often covered by Medicare after a hospitalization.  Your discharge planner can assist with making this referral and the patient may choose which provider they would like to use.  Make sure you consider the questions above and determine if you and your family can meet your needs or if you may need additional home care services.  While these services are typically not covered under Medicare, a little bit of extra support can make all the difference in your safe transition home.

Shannon Martin, M.S.W., CMC, is Director of Communications at Aging Wisely, LLC (http://www.agingwisely.com), a professional care management and patient advocacy organization and EasyLiving, Inc. (www.easylivingfl.com), a licensed home care agency, in Clearwater, FL.  Shannon serves as adjunct professor at Eckerd College in St. Petersburg, FL, where she created a course on “Eldercare”.  Prior in her career, Shannon served as social services director and admissions coordinator in an assisted living/skilled nursing facility and worked as a social worker and volunteer coordinator for a large hospice.