Planning Ahead: Tips for Returning Home from the Hospital and Avoiding Readmission

Nothing can be more discouraging than returning home from a hospital stay, only to be readmitted due to something you didn’t anticipate, such as a drug interaction or a delayed recovery from anesthesia. As Kaiser Health News’ Navigating Aging contributing columnist Judith Graham identified in a recent article about how to avoid readmission, “too often institutions don’t take the reality of seniors’ lives adequately into account, making it imperative that patients figure out how to advocate for themselves.”

As we age, we need to be particularly cognizant of how important it is to not just plan ahead but to anticipate that a hospital visit or stay may be in our future. That includes planning for the worst-case scenario, as well as advocating for ourselves and having an advocate at the ready. Thoughtful planning can be the difference between successful recovery or readmission.

Here are a few things to think about ahead of a hospital stay, be it for a planned surgery or something unexpected such as a fall and an emergency room visit:

1. Accept the help you need. Don’t try to do it all on your own. Extra help for a while after a hospitalization is needed by almost everyone. You and your loved ones will feel relief knowing you have a little extra help scheduled.
2. Have an advocate with you—a family member, friend, or professional like an Aging Life Care Manager™. Ideally, your advocate will have knowledge of the healthcare system and can help you ask questions, absorb information, take notes, and take a stand for you if you feel unprepared to leave the hospital in your current state.
3. Ask questions about how to care for yourself at home until you understand the discharge information being presented to you—resist the urge to feel rushed! This is your health and you have a right to take the time you need to understand the discharge instructions.
4. Make sure you understand your new medication regime. What medications should continue, what should be discontinued? Know what the medications are used for, how to take them, and make sure you have what you need on hand when you go home. Get rid of old medications that are no longer needed—this will help you avoid making inadvertent medication errors. Talk it through with your doctor, nurse, and pharmacist. Some medications have two or more different names. Be sure to bring another person with you to listen to the medication discharge instructions. All information should be written down legibly. If you don’t understand, ask questions!
5. Don’t leave the hospital until you know equipment and supplies are at your house. If you need oxygen, your portable oxygen tank can only last so long. Don’t go home unless oxygen is already delivered there. Other essential equipment is just as important—hospital bed, wheelchair, shower bench, grab bars, etc. Don’t try to make do without these items.
6. Schedule a follow-up appointment. It can take a while to get in to see your doctor after you are discharged. Make a follow-up appointment before you leave the hospital. Also, be sure you have a ride to that follow-up appointment.

As Graham reflects further in her article, “It’s a mistake to rely on hospital staff to ensure that things go smoothly; medical centers’ interests (efficiency, opening up needed beds, maximizing payments, avoiding penalties) are not necessarily your interests (recovering as well as possible, remaining independent and easing the burden on caregivers). Instead, you and a family member, friend or caregiver need to be prepared to ask plenty of questions and push for answers.”

Medicare offers a Discharge Planning Checklist for patients and their caregivers preparing to leave a hospital, nursing home, or other care setting. It stresses that “you and your caregiver (a family member or friend who may be helping you) are important members of the planning team.”  Print this checklist and fill it out before any hospital stays. See the list of resources on the last page—agencies that provide community services such as home-delivered meals and transportation to appointments.

As the saying goes, “An ounce of prevention is worth a pound of cure.” The time you invest in planning ahead is the “prevention.” The “cure” is your optimal recovery and without needing to be readmitted.

For a deeper dive into additional considerations and ways to avoid readmission, read Judith Graham’s article, referenced earlier: How To Fight For Yourself At The Hospital — And Avoid Readmission.

Contributor Jullie Gray, MSW, LICSW, CMC, is a Fellow Certified Care Manager with over 30 years of experience in healthcare and aging. She is a principal at Aging Wisdom, an Aging Life Care/geriatric care management practice serving King and south Snohomish Counties. Jullie is also president of the National Academy of Certified Care Managers and the past-president of the Aging Life Care™ Association.

Care Transitions Conference Connects Healthcare and Human Services Professionals

Hospitalizations contribute significantly to the cost of health care—costs borne by insurance companies, taxpayers (Medicaid and Medicare), patients, and families—and take an emotional toll on patients and their families.

This is the sixth year that Aging and Disability Services will convene a conference for hospital and home health care administrators, discharge planners, nurses, physicians, pharmacists, policymakers, social service providers, community leaders, and consumers to discuss new ways to work together to decrease avoidable hospital admissions and health care utilization.

For information about the 2017 care transitions conference, read Care Transitions: We’re All In It Together in AgeWise King County (February 2017). For registration information and more, visit www.agingkingcounty.org/CTconference.