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How to Avoid Hospital Readmission
Sam Aisawa 06/09/2021
3 Minutes

Readmission after an illness or injury is a serious health issue for seniors. However, it is important for seniors and their loved ones to remember that in many cases, readmission is avoidable and can be prevented with a thoughtful post-hospital care plan. To be successful at home many seniors need a reliable caregiver that can help them overcome some of the main preventable causes for returning to the hospital. Consider the following:

seniors readmission to hospital

Nearly one-fifth of all Medicare patients in the United States who are discharged from the hospital end up returning within 30 days. There are many reasons seniors may need to be readmitted to the hospital, but healthcare agencies, hospitals, and Transitional Care Units are focused on finding ways to reduce these numbers and educate patients about how to have a healthier recovery at home. Discharge planners and social workers try diligently to get seniors to recognize and change their behaviors at home that may force them back to the hospital.

If you’re thinking no worries, Medicare has me covered, right? Not so much. Many hospitalizations lead to an interim stay at a rehabilitation facility to regain your footing and they’re not always covered by Medicare, even if you need it. That’s about $450.00 per day, on average. Even if your hospitalization does qualify for Medicare to pick up the tab, after 20 days you’d still be on the hook for $161.00/day. With the average rehab stay at 27 days, that can add up quickly. And, every time you readmit to the hospital, your odds of needing a longer rehab stay or not qualifying for Medicare rehab coverage at all get worse. Put another way - after that first hospitalization, you’re stuck playing a high-stakes game of readmission roulette, with both your wallet and your independence on the table.

Medication is Critical

Some seniors need assistance taking medication in the right amount on the correct schedule. When you consider that, on average, seniors with chronic conditions fill 50 different prescriptions annually, it is not difficult to imagine how someone could get confused when a new medication is added to their regimen. Caregivers can not only remind seniors to take medications as prescribed, but they can also help seniors keep a list of those medications and their dosages so the information is readily available for healthcare professionals. Managing medications is one of the best ways a caregiver can help seniors during their recovery. After discharge, it’s a good practice to check with your pharmacist, doctor, or nurse to determine how to manage new vs. old prescriptions.
Follow-up visits prevent readmission

A full two-thirds of patients readmitted to the hospital would have avoided that trip if they had seen their physicians within two weeks for follow-up. The reasons for not following up vary but can include transportation difficulties and forgetting to make or keep appointments. Hospital staff can aid the senior by setting up appointments for the individual before discharge, but getting to the appointment can still be a challenge. In addition to a host of uplifting care services, caregivers can provide transportation to appointments and keep track of any post-care visits.

Discharge Plans Only Work when implemented properly

Having a discharge plan for the patient before he or she leaves the hospital can be crucial for recovery, but it can be difficult for seniors and their family members to focus on the plan during the stress of the illness and discharge. Caregivers can help the senior follow the instructions, and will connect with family or other approved individuals when there are problems or changes in condition during recovery. They can also help explain the information or ensure that the appropriate person is notified if the patient has questions about his or her course of treatment. This takes the stress off the family and the patient so he or she can focus on recovery. It is always a best practice to have someone with the senior at the time of discharge that can focus on the discharge plan, take notes and ask questions.

Back at Home

Getting a helping hand during recovery can ensure positive outcomes and a return to an active, engaged life. Family members, friends, and neighbors are often willing to serve as a post-hospital recovery caregiver, but there is professional help available for those that don’t have someone available to assist them. In a study by Duke University and Forsyth Medical, as few as eight 3-hour visits during the critical first two weeks post-discharge, to help with homemaking, transportation, meal prep, and personal care, in conjunction with a comprehensive Care Plan and follow-up, was all it took to achieve a 61% reduction in readmittance. For long-term recovery, those who have the assistance of friends and family can benefit from a professional caregiver to provide respite care and support.
A great deal has been done by hospitals and clinics to improve communication and patient outcomes. Being the best advocate you can for a senior loved one will go a long way toward helping them have a positive outcome. Consider this information from AARP on designating someone as the caregiver so they are prepared to help at home.

Relias. “What you need to know about readmission among seniors.” Web. 2016.
American Hospital Association. “Examining the drivers of readmissions and reducing unnecessary readmissions for better patient care 2011 AHA Policy Research.” Web. 2011.
Robert Wood Johnson Foundation. “Ten things you should know about care transitions.” Web. 2013.
Center for Medicare and Medicaid Services


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