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Transitional Care

Ready, Set, Go Home

Reducing Hospital Readmissions - Ready, Set, Go Home

An overnight or extended hospital stay can be overwhelming and stressful for anyone. For seniors, especially those dealing with multiple health issues like dementia, hospital visits can become frustratingly repetitive. Research shows that 20 percent of seniors on Medicare are rehospitalized within 30 days of discharge, with many readmissions occurring within 7-14 days after leaving the hospital.

Blue and Faith has introduced a home care resource called “Ready, Set, Go Home” to assist seniors in avoiding these return trips to the hospital.

Ready, Set, Go Home is a transitional program offering non-medical support to help seniors successfully adapt to their homes after hospitalization. The program aims to minimize the risk of preventable events or mishaps at home that could lead to a return admission to the hospital or emergency room.

How Can Blue and Faith Help Reduce Hospital Readmissions?

Blue and Faith designed the Ready, Set, Go Home program to ensure the best outcomes by providing essential, non-medical personal home care services following hospitalization. In-home services include assistance with:

  • Dressing
  • Personal grooming
  • Bathing
  • Toileting
  • Mobility and transfers
 

Personal caregivers can also help with:

  • Errands
  • Meal preparation
  • Light housekeeping
  • Medication reminders
  • Other routine activities
 

Blue and Faith’s caregivers also provide companionship and conversation to reduce the risk of senior isolation.

Importantly, Blue and Faith can keep a watchful eye on your senior loved one during their recovery and report any concerns to you. Identifying problems allows you to seek immediate medical care and reduce the chances of another hospital stay.

What Causes Hospital Readmission?

Many seniors experience functional decline after hospitalization, impairing their independence and quality of life. Your loved one may feel overwhelmed and exhausted by basic tasks, especially if they have a chronic condition or are recovering from a significant health event, illness, or surgery.

Additionally, medical experts now recognize a condition called “post-hospitalization syndrome,” occurring several weeks after hospital discharge when seniors may be vulnerable to symptoms increasing their risk of rehospitalization. Some patients may also face an increased risk of death during this period.

Signs of post-hospitalization syndrome may include:

  • Lingering fatigue
  • Weakness
  • Foggy thinking
  • Bowel or bladder concerns
  • Increased disorientation
  • Disruptions to sleep patterns, diet, routines, and activity level
  • Increased stress and anxiety
  • Medication-related side effects
 

Post-hospitalization syndrome could make your loved one more susceptible to falls, a relapse of their condition, or another adverse event. Additionally, they may struggle with self-care, household tasks, managing medications, attending medical appointments, or communicating with their medical team about symptoms.

A Discharge Guide for a Successful Return Home from the Hospital Blue and Faith created a Ready, Set, Go Home Discharge Guide to prepare for your senior loved one’s successful return home from a hospital or rehabilitation facility.

You can use the guide to record vital information discussed with a healthcare provider, identify areas where assistance is needed, and determine who (family, friends, neighbors, and/or Blue and Faith) can help and coordinate care at home.

After returning home, your loved one or you can use the Ready, Set, Go Home Discharge Guide to reference information and notes from a healthcare provider. You can also bring the guide to follow-up medical appointments to maintain a comprehensive record of directives and as a reminder for questions to ask.

Post-Hospital Personal Home Care Plan

Professional caregivers can also visit your senior in the hospital or rehab facility and have a plan in place before discharge to ensure you have peace of mind. With input from you and the healthcare team, Blue and Faith will customize home care to meet your loved one’s specific needs.

Contact Blue and Faith to learn more about the Ready, Set, Go Home program if your loved one requires senior care after a hospital stay. Request a free home care consultation from your local Blue and Faith home care agency today.

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