Sequoia Senior Solutions Blog

Comments & Discussions Pertinent to Seniors and Their Families

Preventing Multiple Hospital Readmissions

It is an undeniable fact: Our bodies have a limited lifetime warranty. As we get older, our bodies just simply begin to break down; the inevitable wear and tear of 50, 60, or 70 years of life taking their toll. A significant medical event will often force many seniors to be hospitalized, sometimes for the first time in their lives. Then suddenly, hospitalizations grow more frequent as episodes of readmission occur, often only days after an initial discharge from the hospital.

Reasons for these readmissions include: poor communication with physicians and other members of the patient’s Care Team, conflicting and/or misunderstanding of medical information, missed doctor visits, medication errors during transitions and post-hospital discharge periods.

In the Medicare Care Transitions Act of 2009, the federal government mandates that costly hospital readmissions of Medicare patients be reduced. The proposed legislation advocates that home care services be coordinated with hospitals as part of hospital discharge plans. Backed by numerous recent studies some facts have become notably apparent concerning discharged senior patients who had no follow-up in-home care, nor a cohesive plan provided by a hospital discharge planner:

  • Adults 65 years and older comprise 40 percent of elderly hospitalizations—a group particularly vulnerable following an initial discharge from the hospital
  • 5 percent of Medicare beneficiaries are readmitted within five days of discharge
  • 20 percent are readmitted within 30 days
  • 22 percent are readmitted within 60 days
  • 34 percent are readmitted within 90 days


In another study, patients who lived alone and had no in-home care, were readmitted more than twice as often as those discharged patients who had in-home care assistance.

Another study shows that 40 to 50 percent of readmissions are linked to a lack of community services or follow-up care. It was found that by age 85, more than 50 percent of discharged patients require some form of follow up service for duties that they are unable to perform themselves.

In one specific example, an elderly heart failure patient living alone had been readmitted to the hospital at least four times a year for several years. Once an in-home caregiver was enlisted for his service, he was able to call a nurse instead of just automatically going to the emergency room, thus vastly reducing his frequent hospitalizations.

Health care plans and hospitals alike are beginning to realize that many of these readmissions are costly, affecting quality of service and profitability, and that they could be effectively avoided by utilizing in-home care services to reduce the risk of hospital readmission. By assisting a senior and his or her family with day-to-day post-discharge needs such as medication reminders, meal preparation, chronic illness monitoring, and maintaining ongoing contact with doctors, a caregiver can devote more time, attention, and expertise to the patient than family members are able or are sometimes capable of doing.

Coordinating post-hospitalization in-home care with a hospital discharge planner is the best tactic. Through a discharge management plan incorporating in-home care assistance, the transition from hospital to home can be organized and worry-free. Depending on the situation, a discharged senior or his/her family can utilize the services of an in-home caregiver for anything from a few hours a day, to full time, 24-hour care. Services can be provided on an on-going basis or simply for a specified time period to assist in short-term recovery. A common misconception is that hiring an outside caregiver is expensive. The reality is, however, that the actual costs to families who forego such a service can translate into lost time, lost income, lack of sleep, and sometimes even job loss incurred by a family member trying to personally assist their aged loved one. In many cases, these losses would most easily justify the expense of hiring an in-home caregiver.

Statistics show that seniors discharged from the hospital had significantly reduced rates of readmission when the discharge plan included in-home care services. Overall, numerous studies conclude that in-home care service can, and should, develop a mutually beneficial relationship with hospital discharge planners. This can result in a win-win relationship for all parties involved. Hospitals and insurance plans reduce frivolous costs, and patients and families preserve their quality of life by avoiding lost time and money through unnecessary and repeated hospital stays.

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