Rehospitalization is a significant concern for elderly patients, often resulting from complications that arise after an initial hospital discharge. In fact, one of the main reasons that Carolyn Walsh founded Senior Steps back in 2017 was the issue of elderly people being discharged from hospitals and clinical settings without the proper resources or instructions for at-home care, leading to further decline in their health and often, rehospitalization within months, weeks, or even days. Unfortunately, many elderly people and their family caregivers do not have the knowledge, support, or bandwidth to follow through with proper care at home, especially as it becomes more demanding physically, mentally, and in way of time required.
Rehospitalization can occur due to various reasons, such as inadequate post-discharge care, medication mismanagement, or lack of follow-up with healthcare providers. Elderly patients are particularly vulnerable due to multiple chronic conditions, mobility issues, and cognitive impairments.
A geriatric care manager can play a crucial role in reducing the likelihood of this scenario by providing comprehensive and continuous care tailored to the unique needs of older adults. If you have been considering working with a geriatric care management team, here are some effective strategies and real-life examples of how such a team can make a difference:
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1. Comprehensive Discharge Planning
A geriatric care management team begins by ensuring a thorough discharge plan is in place. This includes detailed instructions on medication, diet, physical activity, and follow-up appointments. For instance, if an elderly patient is discharged after hip surgery, the care manager coordinates with physical therapists to create a home exercise plan and ensures all necessary medical equipment is available at home.
2. Medication Management
One of the leading causes of rehospitalization is medication mismanagement. This is even more likely when a senior is working with several specialists who prescribe different meds that can interact with one another. Geriatric care managers help by keeping open lines of communications between pharmacists and specialists in different facilities, organizing medications, setting up reminders, and educating patients and their families about proper dosages and potential side effects. For example, a care manager might use pill organizers and digital reminders to help an elderly patient with dementia adhere to their medication schedule.
3. Regular Monitoring and Follow-Up
Continuous monitoring is essential to catch potential issues before they escalate. Geriatric care managers conduct regular check-ins, either in person or via telehealth, to assess the patient’s condition and address any concerns promptly. If a patient with congestive heart failure shows signs of fluid retention, the care manager can quickly arrange a consultation with a healthcare provider to adjust treatment.
4. Coordination of Care
Effective communication and coordination among various healthcare providers are vital. Geriatric care management teams act as liaisons between doctors, nurses, physical therapists, and family members. This ensures that everyone is on the same page regarding the patient’s care plan. For instance, if a patient sees multiple specialists, the care manager ensures that all recommendations are integrated into a cohesive plan.
5. Education and Support for Caregivers
Family members often play a critical role in post-discharge care. Geriatric care managers provide education and training to caregivers, helping them understand how to manage the patient’s condition and what signs to watch for that might indicate a problem. For example, they might teach caregivers how to monitor blood sugar levels for a diabetic patient and recognize symptoms of hypo- or hyperglycemia.
6. Home Environment Assessment
A safe home environment is crucial for preventing accidents that could lead to rehospitalization. Geriatric care managers assess the home for potential hazards and recommend modifications, such as installing grab bars in the bathroom or removing loose rugs that could cause falls. These proactive steps create a safer living space for the elderly.
7. Nutritional Support
Proper nutrition is essential for recovery and overall health. Geriatric care managers work with dietitians to develop personalized meal plans that meet the nutritional needs of elderly patients. They might arrange for meal delivery services that provide balanced meals tailored to the patient’s dietary restrictions and preferences.
8. Emotional and Mental Health Support
Emotional and mental health is often overlooked in post-discharge care. Geriatric care managers ensure that patients have access to mental health resources, such as counseling or support groups. For instance, they might connect a patient dealing with depression after a major surgery to a therapist specializing in geriatric mental health.
9. Utilizing Technology
Technology can significantly enhance the care management process. Geriatric care managers may use remote monitoring devices to track vital signs, mobile apps to schedule and remind about medications, and telehealth services to provide virtual consultations. These tools help in maintaining continuous care and addressing issues swiftly.
A senior care management team is instrumental in reducing the chances of rehospitalization for elderly patients. By providing comprehensive discharge planning, medication management, regular monitoring, coordinated care, and support for both patients and caregivers, they create a robust safety net that addresses the unique needs of older adults. For more insights and support on elder care, consider exploring resources and articles from reliable sources like Senior Steps, which provides comprehensive guidance for geriatric care management.
If you’ve been considering working with a geriatric care management team, fill out the 30-second form at seniorsteps.org/book online to schedule a FREE consultation with one of our experts and see if we’re the right fit for you.
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