“Back in the Hospital Again” — A Result of Fragmented, Uncoordinated Care

Getting a loved one home from the hospital is always a relief for both patient and family, but the weeks immediately after hospital discharge are fraught with peril, as many families don’t discover until the patient has to be readmitted for a new problem. This is especially common with Medicare patients: an alarming one in five Medicare patients are back in the hospital within thirty days, and one in three are readmitted within ninety days. Fully half of the non-surgical patients who have to be readmitted in the first month after going home had no followup visit with any doctor during that same month. That means the patients were basically set adrift to fend for themselves. These numbers come from an analysis published in the New England Journal of Medicine, as reported in an editorial in the New York Times.

Leaders in the health care field freely admit that hospital readmissions come about from poor discharge planning and inadequate communication with family members about what they need to do to keep the patient healthy. The president of the American Hospital Association said in a letter to The Times about the editorial: “Most unplanned readmissions can be traced back to our fragmented delivery system, and to the lack of social support programs for many elderly and sick patients.”

What is the answer?

Family members who are assigned by hospitals to take care of a loved one at home need to be very clear on what they are supposed to do. Do not let a family member be dumped on your lap without a clear, written list of everything they need, including medications, therapies, and appointments for return visits. Family members need a lifeline they can call on when things don’t seem to be going right.

The leaders of our health care system are talking about extending Medicare benefits so that nurse managers can coordinate the transition from hospital to home, or teams of caregivers can conduct house calls on recently discharged patients. These are promising ideas, but what is needed right now is for anyone who has a family member coming home from the hospital to speak up and insist on clear instructions and advice. Being forceful and clear can help the caregivers help you to make sure there is a well thought out plan and that you can realistically carry it out.

Patrick Malone’s new book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst, has a chapter on how family members can become effective patient advocates when they have someone in the hospital. The chapter includes a list of key checkoff points that you need to understand when a loved one is discharged to your care. You need to have at a minimum:

* A written set of discharge instructions.

* A specific appointment with the doctor in charge for a followup visit.

* A list of bad things to watch out for, and the contact person to relay this information to.

* Written lists of all medications that need to be taken, when and how; plus all therapies that need to be done with similar detailed instructions.

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