Hospital readmissions are frustrating for individuals and families. We believe that bridging care from the hospital to home is key to ensuring a safe and seamless discharge home. Transitioning older Australians back into their own homes and routines with proper support and assistance, is vital to their long-term health and happiness.
Care Workers supporting people transitioning home from the hospital can save your independence and billions of dollars! In 2015 it was estimated that the annual cost of unplanned hospital readmissions across Australia was as high as $1.5 billion1.
Readmissions for older Australians are most often caused by incorrect use or discontinued use of medication and/or not attending follow-up doctor appointments. These risk factors increase in cases where the patient lacks a support system at home. Among single-component interventions, involving professional in-home care as part of the transition home, is a proven method of reducing hospital readmissions2.
Going home from the hospital can be a complex and stressful event. As much as you might want to go home to the comfort and familiarity of your own space, you need to ensure you are safe to do so. As it can be overwhelming to go from a hospital where others are taking care of you, to needing to manage on your own without any in-home care. As a result, it is not uncommon to have thoughts such as:
- “What if I am not strong enough to be at home on my own?”
- “Who will take care of me?”
- “I don’t know what to do!”
Ensuring you get answers to these important concerns will prepare you to not only successfully make it home, but to stay home.
The first step to ensuring a successful transition is to partner with an in-home care service, such as Home Care Assistance. In addition to in-home Care Workers, you will have a dedicated Care Manager who can act as the link between the patient, the family and healthcare professionals overseeing the health needs and mapping out a plan to address those needs.
Home Care Assistance Care Managers can:
- Help you or your loved one whilst admitted in the hospital
- Work with doctors, nurses, social workers, and other professionals to provide for your current and future needs as you recover at home
- Arrange for long-term care or in-home care on discharge
- Support transition paperwork
A Care Manager’s reach goes beyond the hospital and can extend to any community partners collaborating with you once you are at home. Helping you have a better understanding of what to expect when you return home will have a positive impact on overall health and wellbeing.
A visit from a professional caregiver at home the day after discharge is the next step in a successful transition. This is often the scariest time for a patient and when you most need reassurance and reminders of the hospital to home care plan. A home visit within three days of hospital discharge goes a long way to prevention of readmission.
Home Care Assistance Care Workers will:
- Support understanding of discharge information
- Support and enable compliance with discharge instructions
- Assess progress and adjust the levels of care as needed
- Monitor and support lifestyle and diet changes that might be part of the recovery plan
- Provide medication reminders
- Provide transport to follow-up appointments
- Empower the individual to regain their independence
- Provide social, emotional, and mental health support during recovery
Time and time again, we hear how people just want to stay in their home as they age. Staying at home promotes better health and can save thousands of dollars in healthcare costs. The right support and education when it comes to the transition back home from hospital can make this an ongoing reality.
Returning home from hospital, it is often tempting to try to keep up with what you did prior to hospitalisation, but this can result in people accidentally hurting themselves, or feelings of weakness or helplessness when things can’t be managed the same way as before. A good transition strategy with proper support can make this time easier, restore confidence and capabilities at home again.
Once released from a hospital, your goal should be to ensure you don’t go back. Case Manager oversight, doctor follow-ups and well-trained Care Workers are the most important pieces to the puzzle that can help prevent patients from returning too soon.
A patient that goes home with proper support and has a smooth transition from the hospital is a patient who stays out of the hospital – and we all want that right?
References:
2 Scott Ian A. (2010) Preventing the rebound: improving care transition in hospital discharge processes. Australian Health Review 34, 445-451
