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4 Questions to Ask Before a Senior Goes Home from the Hospital

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January 5, 2016

Seniors face unique perils from hospitalization. Delirium, functional decline and medication toxicity represent just three problems that tend to affect seniors more than younger patients. At discharge, seniors may feel overwhelmed by the amount of information they must digest, from pages of discharge instructions to a multitude of follow-up appointments they must coordinate. Perhaps this explains why many seniors experience rehospitalization.

According to data from the Medicare Payment Advisory Commission, nearly one in five seniors discharged from the hospital will be readmitted within the first 30 days due to preventable factors like premature discharge or being discharged to an inappropriate setting. Rehospitalization can be costly for facilities, and it can be hard on seniors who may become demoralized due to repeated hospitalizations.

As a senior care provider, you can help seniors avoid readmission by keenly assessing their home environment and ensuring they have adequate supports in place to follow medical orders and receive follow-up outpatient care. Here are 4 questions to ask to potentially reduce senior hospital readmissions.

1. Does the senior live alone?

When a senior goes home after a hospitalization, he or she may require a high level of care for some period of time in order to ambulate safely, perform ADLs, eat nutritiously and get to follow-up medical appointments. Seniors who live alone may lack the support they need to recuperate safely. Before you send a senior home from the hospital, ask whether someone is available 24 hours a day to provide any care the senior may need. If not, consider recommending professional in-home care services to help the senior stay safe and avoid rehospitalization.

2. Is this senior at risk for polypharmacy issues?

Seniors often get discharged home with a slew of prescriptions after a hospitalization— some of which may be in addition to any medications they have been taking routinely. Seniors who take multiple medications may be at risk for polypharmacy issues, including poor adherence to their medications regimen or adverse drug interactions. You can help them avoid possible polypharmacy issues by:
• Evaluating their current medications list, including any new medications and over-the-counter drugs and supplements
• Identifying potential drug interactions
• Eliminating unnecessary or redundant medications
• Creating a simplified medication schedule—or, using a service like Simple MedsSM –to make adherence easier

3. Will the senior be able to maintain a healthy diet?

Hospital food may be the butt of many jokes, but senior nutrition is a serious issue. Eating poorly before or after discharge can put a senior at risk for physical weakness that could lead to falls—and readmission. You can help seniors avoid this scenario by talking with them about their nutrition, how much they eat, and how they plan to prepare meals once they get home. If it appears they will have trouble maintaining adequate intake or preparing nutritional food, consider recommending an in-home care service provider like their local Home Instead Senior Care office, whose professional CAREGiversSM can develop menu plans, shop for healthful foods and cook nutritious meals for seniors.

4. Does the senior have access to transportation?

Obtaining follow-up care on schedule after a hospitalization is important to a successful recovery. Outpatient providers often can catch warning signs of health or recovery problems before they lead to a readmission. Do your senior patients have either the functional ability to drive themselves to and from appointments or to take public transportation? If they do not, help them secure assistance from family members or professional caregivers to take them to follow-up appointments.

For senior care professionals, asking these 4 questions prior to discharge can help their clients avoid rehospitalization and help their facilities avoid the expense of readmissions. When seniors transition home successfully after a planned or unplanned hospital visit, everyone wins.

For additional resources, including sample checklists to help seniors stay safe at home, visit the Prevent Senior Hospitalizations® section of®.

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Thoughts and stories from others
  1. January 15, 2016 at 2:46 pm | Posted by Ursula Johnston

    I would add that these questions should be asked of the person BEFORE the person is even admitted to the hospital. It is a great way to trouble-shoot and to help the patient make plans for assistance post discharge while they have a "clearer" head. Sometimes, while the patient is in the hospital, they decline help or downplay their need because they are confused, don't want to be a burden to others, fear more expenses, or don't want to appear like they are a big baby.


  2. January 8, 2016 at 10:56 am | Posted by Joe Vosters

    Agree that caregiver help is often required but a home assessment (by an OT/PT) should also be done to see if dangers exist or assistive products would be needed. Liftchairs and walkers are old standbys but often the bed area is where mobility problems can be the worst. If that is the case bedrails, Superpoles, Friendly Beds, etc. may be critical to keep them safe- getting in/out of bed (or repositioning in bed) can be dangerous/difficult (or impossible) for many people.


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