Hospital Readmission and
Discharge Safety Handbook

Taking the proper steps for your health and rehabilitation is key for finding success after your discharge. 

While they may seem like optional items at first, rehab and in-home care are key players in a full recovery, especially when an early discharge or a long stay has hindered your mobility. Carefully consider your situation, and always be open to in-home care and rehabilitation options that are brought up by your family, friends, and healthcare professionals.

This can even be an opportunity to come out stronger than when you first entered the hospital!

Safe discharge is often defined by the success of your treatment, but the timeline and criteria to determine that success go further than your initial recovery. When you are ready to leave, it is very important to have a discharge plan in place so that your transition back to regular activities is as smooth as possible!

In short, a discharge plan is a holistic summary from the hospital of all follow-up care, appointments, and medications needed.

Hospitals are required by Medicare to provide discharge planning for inpatients when necessary. The loved ones of patients can take an active role in discharge planning by choosing the best home care solutions.

Your discharge planning can have a huge impact on your long-term success, and both parties should be on the same page when it comes to the success of your primary hospital treatment. While not every hospital is the same in its criteria for discharge, there a lot of similarities that can be pulled out.

Checklist for ensuring a safe hospital discharge

1. Understanding Reason for Hospitalization

   How did you end up in the hospital in the first place? While all hospitalized conditions are serious, there is a wide variance in the long-term risks of your injury or illness. For example, a stroke needs more attentive care than a broken bone and requires more inpatient care. Ask your doctor for the average length of stay for someone in your condition and compare that with what makes your case unique!

2. Considering the Results of Primary Care

   This is one of the biggest markers for success in your care but can also be one of the most complex questions to answer. Generally speaking, if your care has been successful, then discharge is on the horizon. It is up to you and your doctor to make a strong plan going forward to ensure future success.

3. Medication Safety

   Not every medication can have a relaxed dosage schedule. Treatment like dialysis and chemotherapy has to be precisely administered to find optimal results. If your required medication is more strict than others, additional time in the hospital or follow-up visits may be required.

4. Follow-Up Plans

   Even if you are well enough to be released from the hospital, some treatment plans may require follow-up care to ensure the best results. More intense treatment plans may be easier with extended hospital stays and should be considered before discharge.

5. In-Home Care Referral

   If you sustained a more serious injury, it might take some time to get back to full strength. Referrals to in-home care providers can make a huge difference in increasing independence in the home during recovery and reduce the chances of needing additional care in an assisted living facility.

6. Outpatient Communications

   Strong communications with an outpatient facility can help keep you out of the hospital altogether. While it may seem risky to head to a care provider and risk a hospital referral, diagnosing issues early can mitigate the risk for serious problems down the line. Keeping in touch with these outpatient providers can keep you on top of your recovery and avoiding new problems.

7. Patient Education

   Knowing the most about your condition can be the difference between a quick fix and a long, risky stay. When it comes time for your discharge, make sure you are staying up to date on the do’s and don’t’s of your illness to better avoid future problems.

Westchester Family Care’s discharge program bundles the care, transportation to doctor’s appointments, and medication management together to increase the likelihood of success.

To learn more about safe discharge planning, read our blog on how to Plan Ahead for a Successful Discharge or jump ahead to our section on “staying on top of your treatment.

Every patient’s stay is unique, varying greatly in time based on the severity of the illness or injury. The average length of stay (ALOS) in the US is 5.5 days but can easily extend past a month if the patient is in critical condition.

Be patient with your doctors, and always be willing to follow through with the best treatment options for you!

Make a plan with your doctor!

A stay at the hospital is not a cure-all, even when it may feel like it. Discussing in-home care, medication, and rehabilitation with your primary care doctor is a vital part of continuing a smart healthcare plan.

An effective plan with your doctor can be the key to long-term success. According to a study in The New England Journal of Medicine:

• Nearly 1 in 5 (19.6%) of discharged Medicare patients were readmitted within 30 days
• 34.0% of patients were hospitalized again within 90 days of discharge
• The average stay of rehospitalized patients was 0.6 days longer than for patients with similar diagnoses who had been out of the hospital for at least six months

The goal of a discharge program is to improve outcomes by ensuring that the patient doesn’t come back in the first 30 days after their discharge. To give your loved ones support to help them heal at home and avoid rehospitalization, Westchester Family Care has created a 7 to 10-day discharge program.

Rehab is a key resource for regaining your strength and even improving your mobility beyond where you were before hospitalization.

If you are having a difficult time at home, or feel you were discharged too early, rehab is the best way to get the supplemental care you need.

Need more information? Read more about the Value of Short-Term Rehab on our blog!

Here are tips our care team recommends to help make your home a safe place for seniors:

1. Make a fall-prevention plan with your doctor:

   Seeking out professional help is the best choice for your health. Creating a solid plan with your doctor will keep you focused and organized when pursuing the best ways to stay safe.

2. Keep moving:

   Physical activity is a fun way to keep your physical senses sharp, strong, and intact. If your mobility is limited, starting small, picking activities you like, or pursuing rehabilitation treatment are the best ways to begin!

3. Remove home hazards:

   Several items in your home may be severe fall risks or, even worse, dangerous landing spots in the event of a fall. Adding protection, padding, or simply removing these risks goes a long way when making your home safer.

4. Light up your living space:

   You have a better chance of avoiding hazards if you can see them. Adding extra lights or improving the brightness of your current fixtures will help you avoid the pitfalls in your home!

5. Wear supportive footwear:

   Steady footing is a key player in maintaining high mobility. When combined with assistive devices, you’ll be on your way to safe and stable travel!

6. Use assistive devices (canes, walkers, etc.):

   Even though you may believe some of these tools to be stigmatized, assistive devices bring stability to your daily life by adding extra points of contact between you and the ground. A cane or a walker will help you travel safely, even in rugged terrain.

For more resources on preventing falls, check out this In-Home Safety Checklist or jump ahead to our section on Creating a Safe In-Home Environment!

Medicare will typically cover rehab or some home care if a patient has been admitted for three days. This is often not enough care per day or per week, and it diminishes quickly. 

The beauty of working with Westchester Family Care is we can work with a certified Medicare agency to provide skilled services such as physical therapy or wound care while we provide home care. The same caregiver can also provide additional private paid hours, which can expand as the Medicare-covered hours phase out.