The period upon discharge from hospitalization is very crucial - especially for elderly adults. Continuity of Care, when the patient is discharged from the hospital, involves critical elements that enable planned recovery and potentially reduce avoidable re-hospitalization.

According to the Centers for Medicare and Medicaid Services, about 1 in 5 elderly patients are re-hospitalized within 30 days of discharge from the hospital. A significant number of these re-hospitalizations are preventable that occur due to the uncoordinated care pervading the system currently.


Major causes of preventable re-hospitalizations include:

Unclear instructions

Medications not taken as advised

Failure to comply with follow-up visits


Numerous studies have shown that if continuity of care is provided with concerted effort after the patient is discharged, not only is the number of re-hospitalizations reduced, but also the health outcomes turn out to be better. Continuity of Care provided by a meticulous program is vital for any post-discharge care.


Hestia’s Continuity of Care Program consists of:

Coordination with Discharge Planners

Development of post-discharge Care Plan including comprehensive home assessment, if needed, to ensure conformance to the patient’s changed needs

Implementation plan for medication management

Escort for follow-up visits to the required health care practitioners (including setting up appointments and providing transportation).

Assistance with personal care and daily activities of living (ADLs)


For further information, call us at 617.910.2200 or fill out our Contact Form.