How Medical Care at Home Can Prevent Hospital Readmissions


Did you know that according to a study by The Dartmouth Institute, one in six Medicare patients is readmitted to the hospital within thirty days of their discharge? The study analyzed 10.7 million Medicare recipients and their hospital records and found that there was a serious lack of coordinated care after patients left the hospital. According the lead author, David C. Goodman, “unnecessary hospital readmissions lead to more time away from home and family and [to] higher health care costs.” In fact, it’s estimated that these avoidable costs exceed $17 billion annually.

Can anything be done to prevent this unnecessary waste, stress, and heartache for your loved one? The answer is “yes,” and it begins with medical care at home.

Why readmissions happen

To fully understand how medical care at home can prevent hospital readmissions, let’s take a look at some of the most common reasons they happen in the first place. According to the Dartmouth study above, several are as follows:

Patients don’t always fully understand what’s wrong with them

The medical issues older adults face are often complex, and treatment usually involves a lot more than “take two and call me in the morning.” And if they don’t have a thorough understanding of their condition, how can they follow a doctor’s instructions and expect to get well?

It’s times like these that having a medical professional explain things to your loved one can be extremely helpful. Visiting nurses and geriatric care managers are trained in the conditions, medications, and needs of older adults. It’s easy to request that they come to the home and talk through the patient’s treatment plan.

Patients may be confused over how to take their prescriptions

With pills that come in different colors, sizes, strengths, and more, those who take multiple prescriptions can easily get confused. In addition, they need to know which to take and when, with which foods (or without), and how they interact with other medications. With a licensed nurse to provide medication management, older adults and their families can easily get informed about prescription regimens. If changes are needed, such as a different dosage or even a different medication, the nurse can recommend alternatives for the patient to present to their doctor.

Hospitals don’t provide patients or doctors with important information

Poor communication is rampant in every industry these days, and sadly, healthcare sometimes follows the trend. This is especially true around discharge time, which can be hectic and rushed. Important things, like test results or follow-up instructions, can fall by the wayside. A geriatric manager who visits the patient at home is well-versed in how to navigate the confusing and fragmented state of aftercare. They can make phone calls, request documents, and relay key information to the rest the healthcare team.

Patients fail to schedule follow-up visits

Far from being a mere formality, follow-up visits are a crucial part of maintaining older adults’ health after hospitalization. These visits could be with their doctor, physical or occupational therapist, or any other healthcare professionals recommended during their hospital stay.

Unfortunately, a variety of factors can lead to patients not attending these appointments. Some don’t know they’re supposed to (see the paragraph about poor communication above). Others forget, and still others don’t understand the importance of the visits and assume they can be skipped. Many don’t have the cognitive abilities to make and keep appointments, or lack transportation to and from the practitioner’s office. A visiting nurse, care manager, or home health aide can address all these issues – including the transportation one!

Don’t delay getting medical care at home

Older adults, like most people, dread the idea of going to the hospital. But if there’s one thing worse than going there, it’s being readmitted after you’ve left. That’s why medical care at home can mean the difference between functional aging and a major healthcare event. Be proactive in protecting your loved one: address home care before the hospital discharges them home.

If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home care for older adults. Contact us to find out more.

Institute on Aging

Institute on Aging

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Three and a half years ago, Maggie Fang started her journey as an Assessment Specialist in the Support at Home Program at IOA. Her excellent people skills enabled her to manage a caseload of older adults and individuals with disabilities, helping them receive homecare to age in place. Maggie was selected to pioneer the Temporary Respite Caregiver Support program, and we are delighted to have such a skilled and dedicated individual leading our newest program at IOA. Thank you, Maggie, for your exceptional work! 

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At Insitute on Aging, we are committed to attracting and retaining top talent, and we are incredibly fortunate to have Manuel Martinez on our team. With his extensive expertise in housing and community resources, Manuel has been an invaluable asset to our organization. Recently, he was promoted to the role of Assessment Specialist II in our Adults with Disabilities - Home Delivered Meals program. In addition to managing a caseload, Manuel has demonstrated exceptional leadership skills and has become an expert in program management. We are grateful for Manuel's unwavering commitment to IOA and the community we serve. Thank you, Manuel, for your dedication and passion in making a difference in the lives of others. 
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In honor of #SocialWorkMonth, we're shining a spotlight on one of our exceptional social workers - Patty Myers! 

Patty has dedicated her career and volunteer efforts to support older adults and adults with disabilities in San Francisco. As the Resident Services Coordinator for Institute on Aging's Support in Independent Living program, Patty wears many hats to ensure that the 120+ residents of Martin Luther Towers Senior Housing can age in place comfortably. Her talent for connecting individuals with resources has enabled her to go above and beyond to ensure accessibility and inclusivity for all. Patty's commitment to her work has been unwavering, and we are grateful to have her on our team at IOA. 

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