January 11th, 2012 at 10:13 am
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Improving elder health care transitions

by Carol Bursack

Fortunately for me and my family, I was able to make myself available to help each of my elders after their many hospitalizations. Typically, however, many families simply don’t have anyone in a position to help, and elders go home only to return quickly to the hospital setting because they didn’t have the community support needed for recovering.

Billions of dollars are spent annually by elders returning home from hospital stays. According to the US Administration on Aging, almost one out of every five Medicare patients ends up back in the hospital within 30 days. Most of these readmissions are due to poor transitions due to poor communication and medical mismanagement.

Caring for elders through community support

The Centers for Medicare and Medicaid Services (CMS) have been trying to address this problem. In April 2011, they launched the Community-based Care Transitions Program to reduce preventable readmissions among patients covered by Medicare. This program provides up to $500 million to community-based organizations that partner with eligible hospitals for care transition services that include “timely, culturally, linguistically-competent post-discharge education, medication review and management, and patient-centered self-management support within 24 hours of discharge.”

As with many promising government programs for elders such as Medicaid’s Money Follows the Person, these community based programs aren’t available everywhere.

The Next Step in Care Program

A new campaign–the Next Step in Care Program–is dedicated to develop safe transitions for patients between care settings (such as a hospital to home). The Next Step in Care offers a guide that can help families address care needs for their elder and plan for follow-up care after hospitalization. Using this guide will help families remember the basic questions they need to help their sick elder address:

  • What do they need to bring to the hospital?
  • If they are not going to be well enough to care for themselves when released, where will they go?
  • Will they need help getting around?
  • Will they need equipment and supplies?
  • Will they be able to take the appropriate medications without help those first days out of the hospital?
  • Who will assist them?
  • How long will they need assistance?

For more information, visit Community-based Care Transitions Program

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