Avoiding Hospital Readmissions

Hospital Re-admissions

Statistics show that nearly 25% of all Medicare patients return to the hospital within 30 days of being discharged. More than 75% of Medicare re-admissions could be prevented if the patient had care and support after they were discharged from the hospital.

Causes of Readmission

Many of our elderly residents have moved to Arizona for the moderate climate, leaving their children and other family members behind. A hospital stay for any reason is traumatizing for anyone, but more so for an elderly person or someone who lives alone.

Four main reasons for readmission are:

1. Little or No Follow Up: more than half of patients who are readmitted within 30 days did not follow up with their primary care doctor.
2. Lack of Proper Medication Management: 75% of patients fail to take their medications correctly due to the inability to understand the directions or remember a new medication schedule.
3. Poor Communication: More than 50% of patients do not communicate changes in their condition to their primary care doctor. What could be a simple office visit ends up being a readmission.
4. Living Alone: A person that lives alone has a 50% or higher chance of being readmitted.

Our Solution:

Assisting Hands Home Care will provide any combination of the following services as needed:

• Meet you at the Hospital Prior to Discharge (if possible)
• Coordinate with the Hospital Discharge Team to Create a Detailed, Individualized Care Plan
• Schedule Care to Start When you Arrive Home
• Perform a Home Safety Evaluation
• Pick up new Prescriptions/Medication Reminders
• Assist with Scheduling Follow up Doctor Appointments
• Assist with Transportation to Doctor Appointments
• Monitor Change in Condition and Report
• Assist with the use of new Equipment (wheelchair, walker, Hoyer, etc.)
• Fall Prevention, Awareness, and Education
• Illness/Recovery Specific Education
• Communication with Primary Doctor or Nurse
• Personal Care Assistance
• Meals and Proper Nutrition
• Light Housekeeping/Laundry
• Companionship/Supervision for Safety and Peace of Mind

Caregiver Education

We hire experienced caregivers and/or CNA’s to provide care. We offer a variety of educational topics and information to educate our care team on the most common issues that affect a patient when discharged from the hospital. We also provide patient specific training and education as needed.

Our Caregiver Education Includes:

• Alzheimer’s and Dementia Care
• Parkinson’s Care
• Post Hospital Care
• Dealing with Difficult Behaviors
• Fall Prevention
• C.O.P.D. and C.H.F.
• Stroke Recovery
• Heart Attack Recovery
• Post-Surgical Recovery
• Diabetes
• Safe Transfer Techniques
• Monitoring Change in Condition
• Documenting and Reporting Procedures

Our caregivers must also have the following:

• Level 1 Fingerprint Clearance Card
• CPR and First Aid Training
• A Negative Tuberculosis (TB) Test