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Care Transitions: Avoiding Hospitalizations

In October 2012, Medicare began penalizing hospitals for high readmission rates due to changes brought about by the Affordable Care Act (ACA), also known as health care reform. If a complication forces patients recovering from a heart attack, congestive heart failure (CHF) or pneumonia back into the hospital within 30 days of discharge, this readmission incurs the penalty. This change sparked many medical centers to create hospital readmissions reduction programs trying to solve this problem with care transitions between hospitals and homes. This includes working with many other care providers, including home health care agencies and home care agencies like Homewatch CareGivers.

There are four main areas of concern Homewatch CareGivers helps with in efforts to reduce hospitalizations:

1. Medication Mismanagement

This is the No. 1 reason for hospital readmissions – problems and mistakes with medication cost hospitals $290 billion a year. The elderly are especially vulnerable to medication problems because among seniors with at least three chronic health conditions, 73 percent take five or more medications regularly, but more than half do not take all their drugs as prescribed.

Homewatch CareGivers knows how to keep your loved one safe by helping with medication reminders, monitoring usage, and reporting and communicating any errors with medical professionals and family members as part of our client care coordination program. An in-home caregiver is an essential pair of eyes to keep watch and help your loved one avoid any dangerous medication accidents. With a care navigator on hand to focus on preventing mistakes, the risk for a hospital visit decreases dramatically. Medication problems can also often cause an unintentional fall.

2. Falling

An elderly person weakened by a hospital stay or a chronic illness is often unsteady on their feet. They could be dizzy because of new prescriptions or medication mismanagement, or their legs could be infirm, unable to hold them steady. One in three adults age 65 and older falls each year.

One of the first steps Homewatch CareGivers takes is performing a free fall-risk assessment in a new client’s home. This assessment looks for easily fixable problems, like rugs or power cords, which can cause an unintentional fall. Additionally, caregivers can help clients in and out of bed, a bathtub, or a wheelchair.

3. Missing Doctor Appointments

Doctors recommend that all seniors with health issues get regular checkups and follow-up medical appointments. Despite that advice, 1 in 3 adult patients do not go to a physician’s office within 30 days of getting out of the hospital. Others ignore nagging problems that may be indicators of more serious issues.

It is a surprise to many that a major reason people do not go to these appointments is because of personal hygiene. They do not want those at the doctor’s office to see that they cannot do simple tasks on their own, like taking a shower. The personal care provided by Homewatch CareGivers keeps this from happening. Caregivers can help with bathing and grooming, making sure your loved one feels presentable. The possibilities for help do not stop there. Caregivers can drive your loved one to and from medical appointments, and while they are there, a caregiver can take notes and share them with family later.

4. Failing to Follow Orders

Many people simply do not take the steps they should to stay healthy. A person diagnosed with heart disease or diabetes must change their diet and increase their amount of exercise. Doctors and therapists prescribe specific activity for patients to keep them healthy, whether they are just out of the hospital or just after first diagnosing a chronic condition.

In-home caregivers help your loved one prepare healthy meals, making sure they follow any dietary guidelines, and encourage your loved one to exercise. These types of activities are a change from the norm and it’s helpful to have a third party help make them happen. Taking on this burden of care also decreases family tension and often brings a family closer together. Additionally, the professionally-developed Homewatch CareGivers University gives caregivers the opportunity to learn what meals and activities are appropriate for specific chronic diseases. However, our approach keeps patients from both a hospital readmission and from going into the hospital in the first place.

The Navigating Care Solution

Learning to live with a chronic condition and a high risk of hospitalization does not mean a person can’t live life to the fullest. Homewatch CareGivers is dedicated to empowering people to navigate the health care system for the help they need. By Navigating Care, Homewatch CareGivers guides entire families through the maze that is a loved one’s senior care.

Successfully Navigating Care leads to improved care outcomes for each patient, addresses individual needs through person-centered care, reduces overall medical costs and improves the health of the overall senior population.
Navigating Care is best explained through five interlocked parts:

Client Care Coordination

Care cannot exist in a vacuum. To help with care transitions, many agencies created Accountable Care Organizations (ACOs), which are partnerships between care organizations that work to ensure that each member of this care continuum does its part to provide the best care possible. Part of our Navigating Care solution is to personalize this communication. Helping families navigate what is essential to cater to their individual loved one’s needs prioritizes what is truly important. This coordination between care agencies requires open communication between caregivers and medical professionals. While helping seniors go to doctor appointments, caregivers can supply medical professionals with the existing care plan. Nurses and doctors can look at what is working and find ways to improve the overall care. By working together, seniors in need of adult healthcare get the most out of all the help available. Just because care is about an individual, it does not mean it has to be done alone. The best home health care agencies work with all parties involved so you know your loved one is safe.

Dynamic Person-Centered Care Plan

No person’s treatment is ever the exact same – a care plan must be unique to their specific needs. Instead of focusing on what disease a person has, Homewatch CareGivers believes in customizing care to make sure the most critical facets of care are fulfilled. This person-centered approach to care is the difference between truly living the waning years of life and merely surviving them. Caregivers should treat those in need of elderly healthcare the same way they would treat their own family members. This goes beyond helping them with activities of daily living like bathing and grooming and becomes about encouraging and empowering both seniors and their families to participate in their own care. By involving them in the experience, the care becomes personally rewarding and helps them get the most out of each day.

Recognizing Red Flags

The open communication between caregivers and medical professionals goes beyond Client Care Coordination. Caregivers and family members are on the front lines and act as the eyes and ears in the home every day. They witness activities that can dramatically alter what is required to provide the best adult healthcare. Equipping caregivers and families with the ability to raise red flags is critical. This behavior requires an understanding of the person’s diagnosis, but also of other health and safety issues in the home, such as fall risks. Homewatch CareGivers believes strongly that proactively bringing any red flags the attention of other parts of the circle of care can prevent incidents before they happen, helping seniors avoid trips to the hospital.

Medication Management

This part of our Navigating Care solution directly addresses the medication mismanagement issues that send so many seniors into the hospital. The goal is to help seniors and their families understand the importance of in-depth knowledge of what is being taken, what side effects the medications can cause, and how to manage a dosage schedule. By teaching the family how to keep their loved ones safe, it limits the ever-present risk of a hospitalization due to medication errors.

Lifestyle Management

Addressing a person’s individual care needs goes beyond simple companionship. Caregivers can help seniors and their families take ownership of newly prescribed diets and exercise programs recommended by health professionals. By making sure seniors stay current with their health plan, attend regular doctor visits, and go through prescribed testing and evaluations, it avoids the pitfalls that lead to medical complications that can make a person’s health rapidly deteriorate. Elder home care services should not just meet basic needs – elderly care should give each person the life they deserve. 

It’s important to understand that while Navigating Care helps keep people from hospital readmissions, it is also a proactive program that helps prevent initial hospitalizations. Caring for a loved one is not simple, but it does not have to be overwhelming. Our care navigators can help you figure out what is the best next step at each major development.