The transition from hospital to home poses significant risks to patients, especially the elderly, and gaps persist in care during this crucial time.
Elderly patients, in particular, may be discharged to their homes or a nursing facility while still facing acute illnesses, potentially coupled with chronic conditions, according to an article from Kaiser Health News published in USA Today. Such patients may not have access to needed medications, food and medical equipment, and many do not have relatives or caregivers who can assist with daily tasks.
“There are gaps in care, there are gaps in communication, there are gaps in adequate preparation for patients and families,” Mary Naylor, a gerontology professor at the University of Pennsylvania School of Nursing, told the publication.
As hospitals may receive penalties for excessive readmissions, many organizations now seek out programs to better coordinate care and ease the transition for patients after discharge. For example, in San Diego County, the Aging and Independence Services agency has put federal funding into a partnership with four regional hospitals to assist more than 50,000 Medicare beneficiaries who face the highest risk for complications at or after discharge, according to the article.
The program is not a universal solution, according to the article, as it is unable to treat all Medicare patients and those in nursing facilities are not eligible. But, it has saved Medicare an estimated $13.8 million between 2013 and 2015.
Furthermore, clinicians must address complications before discharge, when physicians read off a list of instructions to patients, some of whom may be unable to understand them due to dementia or other memory issues, the article notes. Also, primary care doctors may not know that the patient was admitted to a hospital, which can confuse the follow-up process. To avoid these problems, and to ensure that elderly patients have access to needed resources, caseworkers should take time to ask questions and make sure all stakeholders are completely and adequately informed.
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