Landmark research done by Eric Coleman and Mary Naylor found that lack of support, communication, and guidance during care transitions play a major role in hospital readmissions. Transitioning seniors home or wherever they call home, is an important step in ensuring they don’t return to the hospital for things that could have been avoided.
Take medications for example. While your aging parent was in the hospital she may have been prescribed one medication but at the TCU she was prescribed a different one for the same problem, and finally once she was sent home, the discharge instructions list a generic form of the prescription because that’s what your mom’s pharmacy uses – three different names to remember and how do you know if they are all the same? You can see how confusing this can get. But medications not properly taken can lead to serious, avoidable issues.
After your older loved one is discharged home from the hospital, skilled nursing facility or even the transitional care unit (TCU), she may receive a call from the hospital, doctor’s office, or TCU checking in on her. These transitions calls are the perfect opportunity to review your aging parent’s status, even if you think she is making progress with her care at home. As Eric and Mary pointed out in their study, communication is the key to success in keeping seniors independent for the long-term.
Coleman and Naylor in their research discovered that these four key principles can make the biggest difference between seniors staying independent at home or ending up back in the hospital:
- Medication management – how knowledgeable are you or your aging parent about the medications prescribed for her? Is there a system in place to ensure medications are taken properly and as scheduled? This is one of the main reasons for re-hospitalization.
- Seeing a primary care physician within 7-14 days of hospital discharge – many seniors ignore this critical order because they think they are doing fine once they are home. You may be seeing progress in your aging parent but that’s no reason to ignore the follow-up physician appointment. Pay close attention to what is written on your discharge paperwork to know when to follow-up with your physician. Regardless of how your older loved one is feeling, follow-up anyway and discuss future plans to keep it that way.
- Understanding hospital discharge orders – do you understand all the instructions and know the red flags you should pay attention to that might send your aging parent back to the hospital? With so much happening at discharge, the details of these instructions can often be overlooked. Don’t hesitate to call the hospital or TCU for clarification once your mom is home.
- Address psycho-social needs – make sure the in-home senior care provider you are working with includes psycho-social needs in your senior’s plan because a greater sense of well-being will increase quality of life now and for the long-term.
At Lifesprk, Lifesprk Life Care Managers (nurses) use these four principles in our whole person senior care model because we’ve seen the proven results that occur when seniors and their families have the Life Care Manager as an advocate and guide to help follow-through on these critical steps post-discharge. We know transitioning home can be a stressful time, and the added support and guidance of a Life Care Manager as part of your in-home senior care services can be a great option to help your mom successfully acclimate once home and stay there.
If you need help with transitioning an older loved one home or understanding what senior services your aging parent might need to be successful long-term, call us.
For more information on care transitions, please contact a Lifesprk Navigator at 952-345-0919 or email ShineOn@lifesprk.com.
