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4 discharge tactics to reduce senior readmissions

In light of the recent Readmissions Reduction Program under the Affordable Care Act, numerous hospitals and medical industry experts are examining new approaches that will decrease the rate of hospital readmissions.

"The Centers for Medicare and Medicaid Services estimates $15 billion is spent annually on readmissions for Medicare patients, with $12 billion of that amount being preventable," said Jeff Huber, president and COO of Home Instead Senior Care, a provider of non-medical in-home care services for seniors. "This is an issue of significant concern to everyone in the healthcare field. There are a number of simple and cost efficient best practices that healthcare organizations can easily implement as they work to decrease the number of unnecessary senior readmissions."

Huber spoke with Healthcare Finance News and outlined four discharge recommendations that can reduce senior readmissions.

1. Inquire about the post-discharge environment
 Before being discharged from the hospital, the discharge planning staff should be informed about the environment the senior is going back to so they can assess whether any additional in-home care or adaptive equipment may be needed to better facilitate a smooth recovery. "The post-discharge environment should be tailored to the senior's recovery needs, which may entail assistance or special equipment to conduct everyday activities, such as bathing, dressing and eating," explained Huber.

2. Implement an integrated approach to post-discharge care 
Post-discharge care for seniors is most effective when integrated among various experts, including trained medical staff, family members who best know the senior who can offer moral and social support, and professional in-home caregivers to employ expert knowledge and experience. "The United Kingdom recently established an integrated care pilot program for seniors with the results of the program suggesting that well-managed integrated care can reduce the number of hospital readmissions among elderly patients by 20 percent," Huber said.

3. Provide clear discharge instructions 
One of the key factors of hospital readmission among seniors is a misunderstanding of the discharge instructions. It happens frequently: an elderly patient leaves the hospital with a stack of complicated paperwork, dozens of medications that all have different timeframes in which they need to be taken and limited instructions on how to manage it all. "To resolve this issue, the discharge planning staff should provide clear, straightforward post-discharge instructions that are easy for non-medical experts to understand," Huber said. "The staff should closely review them with the senior, the senior's family members, and the in-home care professionals before discharge. It is also important that the planning staff help the senior's caregivers understand what various signs and symptoms might mean during the recovery process. Finally, there should be a designated hospital contact that works with the senior's integrated team to answer questions and monitor the senior's post-discharge progress."

4. Continue to adjust the post-discharge plan 
"Individualized, tailored care is essential to ensuring a successful recovery, and the post-discharge plan should be monitored and adjusted based upon the daily needs of the senior over time," Huber said. The hospital contact in charge of the post-discharge should work closely with both the family and the professional caregivers of the elderly patient to monitor progress, keep records and modify the plan of care to meet variations in need. This may start with intensive care and then move to less-intensive care as the senior recovers. It may also include increasing support if a senior's health begins to decline over time.