Last year, Forbes published an article that those of us in elder care and home care already understood very well. The article, by Robert J. Szczerba (@RJSzczerba), talks about the fact that coming home from the hospital can be a lot more dangerous than many folks realize. Without trying to be facetious or disrespectful of the work done in hospitals, we know that is already a dangerous place to be, with a high frequency of viruses and bacterial infections and other problems. We go to the hospital only when we have to do so. As Szczerba puts it, “After a stressful stay in the hospital, your doctors have finally given you the green light to return home. A sigh of relief passes over you with the realization that the worst is behind you.”
However, he continues, “Not so fast …” In fact, there is a much to high likelihood of being readmitted to the hospital, “if proper precautions aren’t taken.” As we know, at Support For Home In-Home Care, he is so right. The author points out,
- One in five Medicare beneficiaries is re-hospitalized within 30 days of discharge; one in three is readmitted within 90 days.
- More than 20% of older Americans suffer from five or more chronic conditions that account for 75% of total Medicare spending—mainly due to high rates of hospital admission and readmission.
- It is estimated Medicare spends approximately $17.4 billion in annual readmission costs.
Because of this, it’s important to find ways to improve transitional care in order to decrease the likelihood of an adverse event or readmission.
The key phrase in that quote is “transitional care”. I have written many times about this topic, often referred to as continuum of care, as well. That continuum includes everyone involved in the health care of an individual, including herself or himself, family caregivers, professional caregivers and clinicians, including hospitals, clinics, home health agencies, perhaps even hospice agencies.
That continuum is or should be always active for us all, but it is especially critical when a medical crisis arises. All too often, and this is sadly true even in Szczerba’s article, care transitions focuses on the clinicians, ignoring the non-clinical providers of care. This is reflected in the author’s attempt to explain care transitions. He says the term describes,
the movement patients make between healthcare practitioners and environments as their condition and care requirements change. For example, a patient might receive care from a specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she might receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition. “Transitional care” is the set of actions designed to ensure the coordination and continuity of healthcare, as patients transfer between different locations or different levels of care within the same location.
There are many good points made by the author, but, until he and many of the folks he writes about begin to grasp the amount of healthcare provided by non-clinicians, including home care aides and family caregivers, it just ain’t gonna change much.
Nevertheless, some of the strategies the author discusses, pulled from the work of the Betty Irene Moore Nursing Initiative (BIMNI), funded by the Gordon and Betty Moore Foundation, is extremely important advice (full disclosure: as an 18-year veteran of Intel Corp., I have to say that I never met a greater gentleman, in every since of the word, than Gordon Moore; but that’s another story):
- Understand your medications and ensure you talk to your doctor or pharmacist about how to take them. In our world of Support For Home, that often means ensuring that the family and / or professional caregiver associated with the patient’s care is absolutely up to date.
- Make sure to schedule and go to follow-up appointments with your doctor. Again, in the case of elder care, especially where there is dementia or non-compliance involved, the professional and family caregivers’ role here is huge.
- Inquire about referrals to community services, such as free transportation to follow up appointments and Meals on Wheels, and take advantage of them. As the author points out, this is especially important for folks who live alone.
- Ensure anyone taking care of you is engaged in all conversations throughout your healthcare experience. This may well be the most important strategy of all, as is probably evident from my comments above, but the author includes some sub-bullets that emphasize the point:
- 40 to 80% of medical information provided by health care practitioners is forgotten by patients immediately.
- Nearly 20% of patients said their health had suffered due to poor communication for varying reasons.
- 52 million informal [and many more professional] caregivers provide care to adults (aged 18+) with a disability or illness.
There is “more to the story,” but this hopefully makes the point. Being released from the hospital is only the start. If good clinical and non-clinical care is not provided after release, your escape may be a short one.
Best wishes. Bert