Avoiding Hospital Readmissions with Transitional Care

Once someone has been discharged from the hospital, they need extra assistance with the aftercare. Being in a hospital is hard, but help is always available from trained professionals like doctors and nurses.

How about once the patient is discharged and allowed to go home? The transition from hospital stay to home or care facilities is a vulnerable period for patients. They still need a lot of care and help even though they were well enough to be discharged. 

Readmission happens when a recently discharged patient doesn’t receive proper care and support, especially in the first 30 days, and they end up being admitted to the hospital again. Readmission to a hospital is quite common due to a lack of communication and coordination. This mostly affects the patient and may cause distress; however, it can also affect their loved ones. 

Additionally, hospital readmission has a huge financial impact on the patient, family members, or the healthcare system.

To avoid readmission, transitional care intervention is required. The main goal of care transition is to avoid readmissions and help the patients. 

What Is a Transitional Care Intervention? 

Transitional Care Intervention (TCI) is a set of actions implemented to make sure that proper care and support are provided to patients who are transitioning from one place to another, usually from a hospital to a facility or home.

This is to make sure that all necessary medical procedures and medications are continued, as well as address any new concerns that may develop. 

Transitional care intervention is usually used for older people or patients with comorbidities as they require more attention. Seniors and patients with comorbidities are more prone to lapses in care when moving from a hospital to a facility or home, which can contribute to readmission. 

Most of the time, these patients are more vulnerable and sensitive, and at higher risk of hospital readmission. Sometimes, they feel embarrassed about asking for assistance. They sometimes won’t communicate properly if they have any symptoms, which can result in it not being treated right away. Having transitional support is critical to ongoing recovery. 

High-intensity transitional care intervention is the key to successfully avoiding readmissions. Below are the common components of transitional care interventions.  

  • Transition Planning

Planning is everything to avoid unplanned readmission. The transition from one place to another must be properly planned and executed. This includes making sure that a trained professional is hired, the family members are well-informed about the patient’s condition, providing coaching and counseling to the patient and their family, and the place to transition to is well prepared and equipped to accommodate the patient.

  • Medication Management 

Some prescriptions have instructions that should be strictly followed. The patient and their family or caregiver will be properly educated about what the medications are for, when they should be taken, and for how long. This is also where the patient will be observed if they are responding well to the medications or if they need to be examined by their doctor to change the medications. 

  • Information Transfer

This step is to make sure that all medical procedures and concerns regarding the patient are being communicated to the doctors, caregivers, and family promptly. Sometimes, patients feel embarrassed to communicate what they are feeling to their caregivers. Their assigned nurses monitor them and make sure to communicate any symptoms to everyone involved. 

  • Home Visit

This is to make sure that the patient is doing well, and that readmission won’t be needed. The patient will be checked if the medications are being taken properly and if medical instructions are being followed by the caregivers. This is usually done within three days after discharge. 

  • Patient and Family Engagement and Education 

This is to make sure that the patient and caregivers are well informed about the patient’s condition and what things need to be done once they are transferred to a facility or at home. 

This is also to encourage self-care for the patients as they are the ones who know what they are feeling or symptoms. Some transitional care providers encourage a teach-back technique where the patients will “teach” their hired nurse the procedures to show if the patient understands them and will be able to do them independently.  

  • Follow-up Care 

This is to communicate with the doctors and family members about every care procedure done for the patient. This is also to make sure that any and every follow-up appointment with the doctor is done and communicated to the family members. 

Some transitional care providers do visits for follow-up, while some do it through telephone. Either way, their main goal is to make sure that the patient is getting better, and their needs are being met. 

Does Transitional Care Intervention Prevent or Reduce Hospital Readmissions?  

Some studies show that most readmissions of recently discharged patients are avoidable with proper transitional care intervention. These studies explored the effectiveness of transitional care interventions, with mixed but generally positive findings.

The Institute of Medicine (IOM) has reported before that one in five Medicare enrollees has been readmitted to the hospital within thirty days of discharge. 75% of these are preventable readmissions. Besides the fact that these readmissions cost the healthcare system millions of money, which could have been used for someone else. These readmissions also cause distress to the readmitted patient and their loved ones. 

Problems about poor patient discharge instructions had been reported, such as information about medications, signs and symptoms to watch out for that may lead to a worse condition and contact information for questions and concerns. Fewer than 50% of patients see their doctors for a follow-up consultation after being discharged. Without proper planning for transitional care, and poor coordination between the acute setting and primary caregiver can result in readmission. It has been shown that high-intensity interventions can reduce readmission rates.

Why Transitional In-home Care is a Good Option for Your Loved One 

  • Continuity of Care 

Transitional home care helps make sure that there’s a smooth transition from hospital to home, which can improve health outcomes and reduce the possibility of complications or readmission to the hospital. 

  • Assistance with Daily Living 

It provides support with activities of daily living, allowing your loved one to live more independently and with dignity as they recover.  

  • Personalized Care 

The care provided is tailored to the patient’s needs to make sure they receive the right support, which can include medication management, wound care, and physical therapy. 

  • Cost-Effectiveness

Providing skilled nursing care at home can be more cost-effective than prolonged hospital stays, allowing for efficient use of healthcare resources.

  • Better Communication and Care Coordination

Hiring transitional home care helps provide better coordination between the caregivers, doctors, and family members. It also allows for better adherence to discharge instructions. 

  • Emotional and Social Support

In-home caregivers can provide companionship, which helps fight feelings of loneliness and isolation that may occur after a hospital stay. 

  • Family Respite

Transitional care services can offer much-needed relief for family caregivers, allowing them to take breaks and focus on their well-being to avoid burnout.  

  • Health Monitoring 

A transitional care team can monitor your loved one’s health during the critical first month at home and provide reports to their doctors, ensuring all healthcare providers are up to date on the patient’s condition. 

Conclusion

Being admitted to the hospital causes a lot of distress to the patient and their loved ones. To be well enough to be discharged can give a sense of relief and hope that a fast recovery will follow. However, the care and support don’t stop once the patient is out of the hospital. There is still a lot of aftercare that needs to be done. To avoid readmission, transitional care is highly recommended. 

It’s hard to be sick and take care of a sick person, and no one wants to be admitted to the hospital again after being discharged. The best way to help them recover fast is to give them proper aftercare. There are a lot of instructions that need to be strictly followed once the patient is discharged and the best people do this are trained professionals. 

Placing the recently discharged patient in a facility that provides transitional care is a great way to help with their recovery, especially in the first thirty days, which is critical. However, in-home care is also a great option as they will tailor the care that they will provide to the patient’s needs, and it gives the patient more independence while being in the comfort of their home. 

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