Hospital Discharge Service

Ready-Set-Go Home

 

Avoiding Hospital Re-Admissions

If you or your loved one has ever been admitted to the hospital, the thing you probably longed for most was to return to the safety and comfort of your own home. According to The Canadian Institute for Health Information recently estimated that roughly 8.5% of patients are readmitted to hospital within 30 days. An estimated 9%–59% of those re-admissions could be avoided by better identifying those most likely to return to hospital within short periods and improving the care they receive before and after discharge. (https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf).

Why Re-admissions Occur

To address the high rate of hospital re-admissions, we must first understand why re-admissions occur. The reasons for re-admissions are varied, but often include:

  • Difficulty managing a disease or illness at home
  • Exhaustion due to disrupted sleep and eating schedules while in the hospital
  • Lack of follow through with discharge instructions
  • Medication issues – does not understand their medications instructions, may skip does, or stop taking them altogether or frequently run out.
  • Does not understand their health condition(s), know what signs to report, wait too long to seek medical advice.
  • Lack of timely follow up with medical appointments or lack of follow through with medical instructions
  • Have the appropriate level of support at home or have underestimated the level of assistance and support needed at home.

Three prong approach

At Senior Homecare by Angels, we address these issues and others by using a three prong approach to care for our clients returning home after a hospital stay.

  1. At the hospital - With Senior Homecare by Angels, we offer peace of mind.  If a client of ours is hospitalized, we visit him or her at the hospital upon request.  We believe collaboration with the hospital discharge planner is necessary to help ensure success at the home.  During the hospital visit, we provide our client with a copy of our “Ready – Set – Go home” discharge planning guide. Specific items in the guide prompts the client to ask pertinent questions about issues that impact re-admissions, such as: symptoms to report, times and dates of follow up appointments, medications, special dietary needs, home equipment needs, etc. This guide we provide you should be initiated prior to discharge and used across the care continuum from the hospital, to the home, and brought to subsequent medical appointments.
    Senior Homecare by Angels will attend and participate in the hospital discharge conference meeting with you, at your request, and ask the right questions and prepare a plan to ensure your loved one has a seamless transition home.
  2. At the client’s home - Our caregivers are the eyes and ears in the home.  Caregivers have a unique insight into why client’s don’t follow up with appointments, why they miss medications does, and other actions that can lead to re-admission. Caregivers can share this information with the case manager, so any issues can be addressed.  Additionally, many of our caregivers are trained to provide palliative and hospice care.  This training enables our caregivers to understand the importance of reporting changes promptly so any problems can be addressed in a timely manner.
  3. At the Senior Homecare by Angels office - Behind the scenes, office staff utilize tools and resources to identify and track clients who are at high risk of re-admission. Staff can help facilitate medication refills, equipment and food delivery services, and regional health care visits, in addition to our non-medical home care services.

Our Goals:

  • Reduce risk of emergency department visits and or re-admissions!   Many clients are admitted to our services directly following a hospital discharge – we identify risk factors and develop care plans to address these problems.
  • Reduce risk of initial hospital admission!  Many of our new and current clients are also at high risk for hospital admission. We assess risk factors on all new clients during the admission process and ongoing as needed whenever there is a change in condition.

How do we achieve these goals?

We are experienced and have tools consisting of resources and strategies to help achieve these goals. Most importantly we have trained caregivers on staff that understand what it takes to deliver superior In-home care, and provide a smooth transition home.