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How to avoid hospital readmissions

Created date

August 24th, 2017
A senior woman conferring with her female doctor while looking at a medical chart.

One of the major challenges of being hospitalized is something we often don’t think about: the risk of being rehospitalized shortly after being discharged to home or a rehabilition facility. It turns out that up to 20% of seniors—as many as one in five—are rehospitalized within 30 days of leaving the hospital. 

This may seem surprising because the assumption is that going home means you’re better and will remain so. The reality is you are typically discharged early in recovery and there remains substantial risk for becoming ill again. After a hospitalization, you are likely to be weak and at increased risk of falls and injury. It is not uncommon to have a decline in a chronic condition such as diabetes or heart disease, even though that condition was unrelated to the reason for hospitalization. There are often new medications or changes in your regimen, which can result in side effects and drug interactions. Generally, your condition changes on a daily basis during the initial weeks following an acute illness. This requires close follow-up and communication and that quite simply is the key to avoiding a return to the emergency room or hospital. 

While communication and a seamless transition may seem straightforward, it remains one of the greatest challenges in medicine today, and when done poorly often leads to readmission. Some of the many reasons for unsuccessful transition include no follow-up appointment, no follow-up on pending tests at the time of discharge, inability to fill new prescriptions, and inadequate discharge instructions. Fortunately, many health care systems have focused on transition, and our national readmission rate has declined to 17.5% from 20% a few years ago. 

Erickson Living’s readmission rate

At Erickson Living communities, our readmission rate for Erickson Advantage, a Medicare Advantage product, is very low—less than half of the national average. This is because we focus on transition, care coordination, and close follow-up of our residents when they are hospitalized. Our electronic health record also helps by allowing us to receive timely and accurate information from the hospital.

The primary care doctor plays a crucial role during and after hospitalization, and you can help by staying in close communication with him or her. First, you or a loved one should notify your primary care doctor immediately if you are admitted. Stay in touch during the hospitalization, and set up a follow up appointment before you leave the hospital. This is a critical step in avoiding readmission as many studies show higher rates when follow-up appointments don’t occur shortly after the acute hospital stay. 

Always read your discharge instructions carefully and have a plan in place to follow them, such as taking daily medicines and handling daily tasks. Hospital staff—discharge planners, social workers, and nurses—can also do most of the footwork, such as obtaining assistive equipment or setting up home health or home support, but ultimately the plan will be yours to follow.

Hospitalizations are difficult and often painful experiences that affect both your physical and emotional health. Needless to say, you want to avoid a return visit and the good news is that by following a few simple steps and communicating well, you can do just that.

Dr. Narrett leads the medical team at all Erickson Living communities. A graduate of Harvard Medical School, he has been providing care for seniors for over three decades.