Re-admission to the hospital within 30 days of discharge occurs in more than 20% of the cases, particularly for elderly patients with chronic diseases such as COPD, depression and heart failure. During hospitalization, the patient’s condition is treated and medications are adjusted with the goal of getting the patient well enough for discharge, often without addressing the factors that caused the admission.
The patient receives limited education about self-care after discharge that could prevent further hospitalizations. The patient is discharged with prescriptions for medications that may differ from the medications they were given during the hospital stay and differ from the medications they used prior to the hospital admission. There may not be a formal hand-off to the patient’s care providers, if any, or coordination to determine whether or not compliance with the hospital’s recommended treatment regimen is even possible at home. The patient may or may not visit their primary care physician for a post-discharge appointment, and there is typically no follow-up by the hospital. When subsequent problems arise, a trip to the Emergency Room is the typical solution.
If your loved one is currently hospitalized or was recently discharged, a Geriatric Care Manager could help avoid readmission. Geriatric Care Managers (GCMs) help their clients during transitions of care including moving clients from home to hospital to rehabilitation and then back home, or to alternative living arrangements. GCMs are advocates for their clients transmitting and reconciling medications and other information from one provider to another; counseling and educating clients and their families about health conditions; navigating antiquated medical information systems and coordinating services to meet changing client needs. GCMs are experts in spotting the gaps in care and filling them.
To learn more about Geriatric Care Managers visit our website www.NSSeniorCare.com