Post Discharge Care
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.
