The New York Times brings to life the importance of addressing avoidable hospital readmissions of our frail elderly after they are discharged from the hospital and spotlights the complexity in doing so in Friday’s Patient Money column. As Alderman points out, “the biggest problem is that no one person takes ownership of a patient.”
The power of a face-to-face home visit by a nurse (photo courtesy of Getty Images)
However, the reality is most family members are not equipped to follow the tips for a smooth transition. More importantly, keeping people out of the hospital goes beyond the discharge and involves overseeing their care at home. While many family members feel they are most equipped to advocate for their parents, challenge information provided at a hospital and oversee their ongoing care, evidence shows that they can make more informed, thoughtful and effective decisions that keep their parents out of the hospital by partnering with a professional geriatric care manager who will bring perspective, experience and a personal touch.
For example, a pharmacist who checks a medication list ultimately has no control or insight into preventing medication errors once the patient arrives home, where he or she might be confusing outdated meds with new ones or have cognitive disabilities that disrupt compliance. On the other hand, care managers can visit the patient at home to understand where medication is kept, see how the medication is administered and dispose of outdated medications. Care managers assess a patient’s entire constellation of factors including medical, home environment, support system of family and friends, financial and legal situation. These professionals are critical not only in developing a care plan based on needs and personal preferences but also in identifying resources for services many are surprised are not covered by Medicare.
Given that an AARP survey recently found that 90% of older people want to stay in place as long as possible care mangers can develop solutions to help people stay in their own homes safely.
