Three Ways Home Care Can Help Seniors Avoid Hospital Readmission

Advice for how to stay healthy at home from the experts at Hebrew SeniorLife Home Health.

Author: Maureen T. Bannan, RN
A Home Health worker helps a patient adjust her pant legs

For patients returning home from a hospital stay, the last thing they or their families want is a return visit to the hospital or the emergency room.

At Hebrew SeniorLife Home Health, our goal is to keep seniors from returning to the hospital by providing the in-home medical treatment, therapy, and help with the essential activities they need to recover. Whether an individual is diagnosed with a new illness, recovering from surgery, or chronically or terminally ill, home health care services can be invaluable.

What is home health care?

Home health care, which can also be known as visiting nurses, sends registered nurses and nursing aides to your home to provide skilled care. It is sometimes recommended by doctors after a hospitalization and can include wound care; medication management; IV therapy; physical, occupational, and speech therapies; palliative care; and more. A doctor’s referral is required and services are typically covered by Medicare and most private insurance plans.

What are the risks to seniors returning home after a hospital visit?

Since we specialize in caring for older adults, we know how easily they can end up in the hospital or emergency room. Without anyone to monitor their progress after a hospital stay or make sure they are taking care of themselves, it’s all too easy for a senior to end up making frequent trips back to the ER.

While all of us would like to avoid trips to the ER, it’s even more important for seniors. Hospitals themselves pose an increased risk of infection for older adults. Plus, if the individual has Alzheimer’s disease or memory issues, there are also increased risks for disorientation and depression.

So how can seniors avoid being readmitted to the hospital after their original stay, and how can home health care help?

Help seniors avoid falling.

According to the National Council on Aging, one in four Americans aged 65+ falls each year. Every 11 seconds, an older adult is treated in an emergency room for a fall. If the older adult has just returned home from a hospital stay, he or she can be weakened by spending a lot of time in bed. They are often unsteady on their feet, making falls an even bigger concern.

Clinical care is key: In-home physical therapy can assess the patient’s mobility, and help with strengthening as well as coach the individual on using assistive devices, like crutches or a walker, if needed.

In addition, home health can help remove fall hazards from the home. A member of the home health team can evaluate the home to assess any areas that could be a risk for someone who is unsteady. They can also provide recommendations for adaptive equipment, like grab bars, railings, and shower chairs.

Ensure seniors are taking their medications.

Many seniors are on multiple medications to manage several chronic conditions. They are especially vulnerable to making medication errors or forgetting to take their medications at all. According to the Centers for Disease Control and Prevention, adverse drug events - harm resulting from medication usage - cause more than one million visits to the ER each year.

The time after a hospital stay can be especially dangerous for older people, who may be coming home with new medications and a new routine to get used to. Home health nurses can help create a plan for medications and make certain that it is followed. 

Help seniors follow doctor’s orders.

After hospitalization, doctors often prescribe specific activities to keep the patient on the road to health. This can include follow-up care with multiple providers, monitoring vital signs or symptoms, and complications to watch out for. Home health care can help explain aftercare and follow-up appointments.

Hebrew SeniorLife Home Health staff work hand-in-hand with hospitals, rehab facilities, and community-based primary care providers to ensure that care is coordinated. Collaboration is key to keeping seniors on the path to wellness and avoiding that dreaded trip to the ER.

At Hebrew SeniorLife, we have become experts in managing transitions of care that may occur as patients’ needs change. Our goals are their goals – better health, a great quality of life, and staying out of the hospital or emergency room!

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Home Health

Hebrew SeniorLife Home Health will send registered nurses and home health aides to your home to provide skilled care any time you need it.


About Maureen T. Bannan, RN

Vice President for Home and Community-Based Services

Maureen Bannan is Vice President for Home and Community-Based Services at Hebrew SeniorLife where she is responsible for the operations of community programs, including certified home health, hospice, adult day health, personal assistance, therapy house calls, and private care.

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