Avoiding Readmission…

The title of Dr. Dhruv Khullar’s March New York Times Well Blog post sums things up.  Most Dangerous Time at the Hospital? It May Be When You Leave. We know the statistics—according to Dr. Khullar’s blog post, 20 percent of patients have a complication within three weeks of leaving the hospital and more than half of those complications could have been prevented or ameliorated. Hospital and rehab discharge planners are doing everything they can to help, but there is a lot of detail they cannot control. To add to the problem, family members are busy, often live at a distance, don’t know what to do, and can’t stay on top of every detail.

This all adds up to the perfect storm for a readmission.

  • Patients and families underestimate what they will need when they go home.
  • Patients are confused about which medications to take and when.  Many are new; doses have changed.
  • Patients do not schedule a follow-up appointment with their doctor.   If they do schedule an appointment, they can't get there or forget to go. 
  • The house is unsafe—scatter rugs to trip on, steps that can't be climbed, kitchen equipment and food in places that cannot be easily reached. The patient can’t climb the stairs to get to the bedroom.
  • Food is out-of-date, unappealing and inedible.  There is no one to chop or strain food.  Patient refuses to eat.

At HouseWorks, we order to the chaos that’s so often associated with a hospital or rehab discharge. During these care transitions, that means providing families with clarity, control, and choice. In response, we’ve created a program called Transition2Home to help families manage a safe return home. We visit clients in the hospital and work directly with the discharge planner to confirm every detail—including confirming the care plan and service schedule, doing a home safety check and recommending adaptive equipment and home modification, providing transportation home, and arranging for nursing services if needed.

Figuring out where to start can be a daunting task. 

Let us suggest:

  1. Create space to deal with the situation.
    • Know that caregiving is the beginning of a journey with no predictable end.
    • There will be points in the journey that are harder than others.
  2. Ask three questions:
    • What must I do now?
    • What can I do later?
    • Who else can do this?  Get help from family, friends and professionals.  Resist the impulse to do it all yourself.
  3. Make a list.
    • Take control by writing everything down, prioritizing, and delegating—just as you would in your professional life. Break down the overwhelming jobs into doable tasks.
    • Trust your judgment. You know more than you think.
    • Build a team.  In addition to doctors and specialists, your team may include an elder law attorney, financial planner, geriatric care manager, and a home care agency such as HouseWorks. 

What we hear from families…

The stakes are high. We are making uninformed decisions, and always during a crisis.  Scared.

We’re focused on the big picture—which has no obvious solution.  We don’t know what to do next.  Overwhelmed.