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Families are often shocked to learn that a loved one is being discharged from the hospital sooner than anyone is ready. Unless the patient qualifies and is willing to participate in rehabilitation, the patient goes home to be cared for by a spouse and other family members.

It isn’t your imagination if you think that hospital stays are shorter than they used to be. In 1980 the average length of stay in the hospital was 7.3 days, and today it is about 4.5 days. The reason? Medicare started paying a rate based on diagnosis rather than the actual costs of care. As a result, hospitals discharge sooner to economize.

Earlier discharges from the hospital have adverse effects on the patient and the family and can lead to readmissions. Today, one in five older adults is readmitted to the hospital within 30 days. The healthcare costs of readmissions are one impact. But, from a patient and family standpoint, readmission means someone did not improve and worsened at home, requiring hospitalization again. Home Care Assistance can prevent hospital readmissions, and we are going to show you how.

How Home Care Assistance Can Help

One of the complicating factors of early discharge from the hospital is the complexity of care needs that the patient may have. It can be overwhelming to families to think about keeping someone safe when they can barely function. Getting home care started BEFORE discharge is the first step in ensuring a safe and successful transition home. Let’s look at the process and tasks that we can provide to prevent rehospitalization.

Identify At-Risk Patients Before Discharge

The first step is to identify the patients who need help the most. Although home health is a critical piece of the discharge plan, it is time-limited, and the patient’s needs may exceed what insurance permits aides to do. In addition, at-risk patients demonstrate difficulty walking, bathing, dressing, cooking, eating, driving, and housekeeping. Falling at this stage is a serious concern.

Contact the Home Care Assistance Liaison

Our home care liaison can meet with discharge planners and the family to discuss an individualized care plan. Home Care Assistance’s Transition Home™ Package helps families manage the discharge process and provides a seamless transition home for effective rehabilitation. It is much easier to make these arrangements while the patient is in the hospital so that families can be confident that their loved one will be taken care of.

Medication Management

A patient may or may not have been managing their medications correctly, but one thing is for certain. Mismanagement of drugs leads to rehospitalization. It is estimated that 26% of readmissions are medication-related.

Home Care Assistance can give medication reminders, and where permitted, dispense medications. When a patient is refusing or not taking medications as prescribed, our staff can alert family and health care providers to intervene before the situation becomes dangerous.

Activities of Daily Living

Home Care Assistance can provide physical assistance with activities of daily living, including mobility, bathing, grooming, eating, and transferring, tailored to the patient’s needs. The risk of falls is very high when someone comes home from the hospital, and assistance with activities of daily living can prevent falls and rehospitalization.

Reinforcement of Rehabilitation Exercises and Movement

Of all the critical and valuable components to recovery and improvement, rehabilitation exercises and movement must be at the top of the list. Home health will provide this skilled service, but home care staff can remind and reinforce safe and consistent activity during and after home health services have ended.

Dietary Considerations and Meal Preparation

Food shopping and meal preparation based on our proprietary Balanced Care Method™ ensures proper and consistent nutrition. Our emphasis is on a healthy, balanced diet and regular caloric intake in line with the physician’s recommendations.

Monitoring Key Indicators and Symptoms

Preventing adverse effects after discharge from the hospital is a critical component of preventing rehospitalization. Unfortunately, the fragmented nature of the medical system and lack of communication about the patient contributes to missed opportunities to intervene sooner.

Home Care Assistance care staff provide this early intervention by communicating immediately to family and healthcare providers when there is a physical decline or change in cognition. A timely response can make a difference by preventing a possible irreparable downturn. The Agency for Healthcare Research and Quality states, “discharge hazards arise from the fact that nearly 40% of patients are discharged with test results pending, and a comparable proportion are discharged with a plan to complete the diagnostic workup as an outpatient, placing patients at risk unless timely and complete follow-up is ensured.”


We cannot underestimate the value of transportation. Often following a discharge from the hospital, there are multiple follow-up appointments with healthcare providers. Unless the family is available to take someone, patients will miss these crucial appointments. Our care team can take patients to appointments and accompany them safely.

Companionship and Advocacy

Being in the hospital is stressful, and depression is prevalent among hospitalized older adults. Emotional support and observation of mood changes are vital to increasing a feeling of well-being and autonomy. In addition, engaging in preferred activities, conversation, and assistance with technology can help prevent loneliness and improve mood.

Home Care and Hospital Readmissions

Preventing hospital readmissions takes a team approach. Home Care Assistance is a crucial part of the team assisting with discharge planning, the transition home, and promoting and ensuring recovery and independence.

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