Readmission to the hospital within 30 – 90 days of being discharged is an issue that Medicare and hospitals have been working to address. The federal government has programs in place that aim to reduce the prevalence of readmissions for patients with several significant medical conditions, and the data indicate that these programs are achieving success.
Poor coordination and communication sometimes play a role in readmissions, so it is necessary that patients and their family advocates take charge and ask the right questions. Lack of follow-up services accounts for many of the readmissions as well, so here are some key questions to ask to ensure you understand the discharge process, your after-care needs, and services you should be receiving:
- Am I eligible for inpatient nursing and rehabilitation services? While most people are eager to return home, older patients in particular may benefit from the supportive environment of round-the-clock nursing services and daily therapy until they recover more fully. Also, find out about hospital-based rehabilitation programs. Typically, days in such programs count as “hospital days” under Medicare versus “skilled nursing days,” thus potentially allowing for more extensive rehabilitation and recuperation, especially useful for certain conditions. Once you’re discharged from the hospital, assuming you’ve had at least a three-day inpatient stay, you may be eligible for Medicare coverage for rehab at a skilled nursing facility, if your doctor indicates that you need this level of care (as opposed to returning home and completing follow-up physical/occupational therapy on an outpatient basis).
- What is the success rate of the provider with patients with my condition? You can research Medicare home health companies and skilled nursing facilities at www.medicare.gov. Do your research and ask other patients or a professional patient advocate such as a geriatric care manager about local providers. Choice of provider is the patient’s choice, not the doctor’s or hospital’s, though they may have suggestions or work more frequently with certain providers (and many hospital systems have a home health branch). If you belong to a Medicare Advantage plan, find out which providers accept your insurance and begin research from there.
- What is my current functional level and in what areas might I need extra in-home assistance with day-to-day activities for the initial period at home?
- When and how will I be provided discharge instructions? Ask for concise but thorough discharge instructions in layman’s terms, with a verbal explanation time. Preferably, plan so that your professional patient advocate or family caregiver can be there when these instructions are explained. Make sure the information from your hospital stay is communicated with your primary care physician and other providers. Take your new medication list to any follow-up appointments.
- What are the “red flags” I should be watching for and symptoms I should be monitoring? What do I do and who do I contact if I notice a concern or change?
To learn more, we suggest the following articles: Hospital Discharge Planning Checklist, Tips for a Better Hospital Stay, and A Safe Return Home from the Hospital. If you believe you are being discharged too soon and do not have adequate support to care for yourself, talk to your doctor or discharge planner about your options. You have the right to appeal the decision to discharge you.
Shannon Martin, M.S.W., CMC, is Director of Communications at Aging Wisely, LLC, a comprehensive care management company and EasyLiving, Inc., a licensed home care agency, in Clearwater, FL. Prior to Aging Wisely, Shannon served as social services director and admissions coordinator in an assisted living/skilled nursing facility and worked as a social worker and volunteer coordinator for a large hospice in Atlanta, Ga.