Everyone looks forward to being able to return to the comforts of home after being hospitalized. However, too many patients will quickly return, especially those over age 65 and with multiple conditions.

THE SCOPE OF THE PROBLEM

Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates.

Within 90 days of hospital discharge, as many as 35% of Medicare recipients will be readmitted to the hospital.

Those at highest risk have certain conditions such as heart failure, COPD (Chronic Obstructive Pulmonary Disease), Psychoses, Intestinal Problems or recent surgery; those taking 6 or more medications; and those being discharged on weekends or holidays. Older patients who live alone were twice as likely to be readmitted if they did not have supportive community services such as home care.

CAUSES

Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent could be minimized/improved.

“Decentralized responsibility is a central defect of the discharge process”, says Judith Black, M.D., MHA, medical director of senior products at Highmark Blue Cross Blue Shield. After a hip replacement, for example, an orthopedic surgeon writes orders, a primary care physician writes orders, and a case manager issues instructions. Patients are often confused and overwhelmed by the process, and even family caregivers often find they do not receive much communication or feel they understand the process.

Communication problems are thus one primary causes of problems after discharge. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Even when communication is good, patients are often groggy, medicated and overwhelmed. This is why it can be vital to have an advocate there to hear the instructions, ask questions and answer the patient’s questions later. Written instructions in laymen’s terms help as well.

Lack of good follow-up care and supportive services is another cause of preventable readmissions. Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. Family caregivers may not be prepared to care for a loved one who needs more physical assistance in a weakened state. The logistics of staying with someone while they are weak or on heavy medication and handling other responsibilities may be too much. Patients without local family support need coordinated services after they leave the hospital such as help with activities of daily living, household help, meal preparation, medication management, physical therapy, transportation to appointments.

SOLUTIONS

Our sister company, EasyLiving, Inc. provides Pinellas County home care support services such as personal care (help with bathing, dressing, grooming), household help, medication management, transportation and a special Transitions of Care Program to help immediately after hospital discharge.

Aging Wisely’s patient advocate care managers can help with the hospital discharge process, ensuring a smooth transition for you or your loved one.  We invite you to review our article on elder patient advocacy and contact us today for help.

Look for our future articles on solutions for hospital discharge problems, including a checklist of things you can do, resources, and ways to be prepared.

A professional patient advocate is someone trained to help individuals (and their families) navigate the often complex healthcare system. Many family members and friends act as an advocate on a regular basis as a loved one faces a hospitalization, health crisis or chronic illness and treatment path. However, a professional advocate such as a care manager offers experience, training and in-depth knowledge of how to ensure the best care and pathway to good health and quality of life.

As stated by the Professional Patient Advocacy Institute, "The cost of healthcare increasingly is the responsibility of the individual consumer, which has made consumers more and more cognizant of the true cost of services and the value of traditional sources of care and information. Yet still today, the healthcare system is not set up like other commodities where comparisons can be made easily. To provide advice when faced with healthcare challenges, an emerging group of healthcare professionals known as patient advocates are positioned to assist consumers in making informed decisions while providing guidance, advice and direction in navigating the complex healthcare system."

What are some of the ways a professional healthcare advocate helps?

*Providing a professional assessment and recommendations for resources, education and care plan options.

*Reviewing your chart and medical records to identify any concerns, questions and to help you and your family understand your health situation and options in lay terms.

*Accompanying a patient to appointments, treatment, ER visits for care continuity. Helping to formulate questions for providers and ensure good communication.

*Helping organize your medical information and create an online, personal health record.

*Assisting during key transition periods (such as hospital discharge, transfer to a care facility, or a switch in providers, where most problems occur) to ensure continuity and anticipate and avoid concerns.

When does someone use a professional patient advocate?

*When recently diagnosed with a chronic illness or acute problem--to locate good providers, evaluate options for treatments and handle the emotional and practical impacts of the diagnosis.

*During key transitions or health crises such as an Emergency Room (ER) visit, hospitalization, hospital discharge to home, inpatient rehabilitation or choosing a care facility.

*On an ongoing basis, especially when managing a chronic illness, multiple diagnoses or some form of dementia, to ensure continuity of care and be a liaison between providers, patient and family.

*To help in organizing records, putting together a care plan, creating an online personal medical record and to generally get a better handle on one's medical situation and be proactive in managing chronic conditions.

*During end of life care, to support patient and family in decision making, emotional support and navigating options.

What are the benefits of a professional patient advocate?

*When you work with an independent advocate, such as our geriatric care managers, you get an independent assessment, someone who works for you and can ensure you get what you need.

*Expertise in the healthcare system (as well as eldercare, social services and related support services).

*Professional training and specialized expertise in the areas you need--someone who can quickly point you to resources and has knowledge of some of the issues you might not even anticipate.

*Emotional support for you and your family. Health crises can be emotional and it can be difficult to manage the practicalities and make clear decisions when facing these emotions. A professional advocate is your sounding board.

Who are professional patient advocates?

Patient advocates come from a variety of backgrounds within the medical world. Some may work for insurance companies, employers or healthcare systems or providers. Others, like our Aging Wisely care managers, work directly for the individual and family--objectively, independently--navigating a range of healthcare systems and providers and providing patients with continuity.

Our Florida geriatric care managers not only have strong professional backgrounds (both academic and experiential) in social work, gerontology, and case management, but continue to pursue specialized training areas. Our team offers experts in areas such as end of life care, Multiple Sclerosis (MS), Alzheimer's/dementia, transitions to care facilities and much more. To read more about our professional care management and patient advocacy staff, we invite you to review our team section.