Transitions from Hospital to Home

“Returning home from a hospital stay can result in unexpected challenges for many seniors. Finding themselves back at home after a hospital stay, many older adults struggle to manage their medications and make follow-up doctor’s appointments as well as obtain the physical assistance and in-home support they may require, at least on a temporary basis. As a result, many older adults do not successfully make the transition home well and end up returning to the hospital. In fact, one in five Medicare patients are readmitted to a hospital within 30 days after discharge. Studies have shown that nearly half of the readmissions are linked to social problems and lack of access to community resources”1 The readmission reduction program for hospitals has been an act of public law since October of 2013.2 Many steps have been taken to make sure the elderly are not discharged from the hospital blindly. Rehabilitation facilities have increased their services. Even many assisted living facilities and Nursing homes have added short stay and rehabilitation programs to help patients return home safely. Once home, local VNA and other Home Health Care companies can continue rehab for a predetermined period of time.

Abundant Blessings Homecare works with all these facilities; Hospitals, Rehabs, VNA’s… and we have been listening to your needs. We have also been listening to the families of the patients we care for. What this means is that our Care Managers will be in the facilities (Hospitals, Rehabs, Nursing Homes…), and available to the Social Workers, Nurses, Staff and families any time they are needed. They will also be in the homes of our patients supervising our team. Sometimes a patient is discharged from the hospital to a facility with future plans to go home with homecare services. In such a case the planning for their transition to home can begin immediately upon discharge from the hospital.  In other cases, patients are discharged directly to home and homecare services are needed immediately, our Care Managers are able to respond to this need and help set this up.

We have always worked very well and closely with local VNA services to support any Rehab efforts (most people will not do exercises unless someone is there to assist and coach them). Most VNA services will provide needed Nursing, PT, OT, etc. as drop in visits. What we provide is homecare services which includes anything from 24/7 to 12 hour overnight services to any combination of hourly services as little as 3 hours a day, even weekends. The schedule will be whatever the family decides they need for assistance, even if it changes.

Our goals are for our Care Managers to form working relationships with all the facilities, to provide a bridge of seamless communication for the patient and their families. This would enable the families to be able keep the same Care Manager helping them for the long term. It is also our aim for our Care Managers to act as liaisons between all the facilities the patient and their families, so patients can get home and stay home safe. This will help unnecessary readmissions to be reduced, families to feel at ease, and the facilities to be informed of their continuous care and know they are in good care with Abundant Blessings Homecare.