COVID-19 and Careplan’s Transition to Home Program- Assisting Older Adults Discharging From The Hospital

Covid-19 Hospital to Home Transitions Program: A Program Benefiting Those Discharging from Hospital to Home During COVID-19

Picking Up Where Your Discharge Planner Left Off

Corona virus is particularly dangerous in elderly, vulnerable patients. In nursing facilities, staff go from room to room caring for residents, passing out food, administering medications and cleaning patient rooms. Even with stringent infectious disease isolation policies, the spread of this highly contagious disease is possible among these already compromised nursing home patients. For this reason, families should consider discharges to home.

A geriatric care manager (GCM) such as those at Careplan can set up telephonic meetings to assess and advise the family. A GCM can make sure all goes well post discharge. The goal is to prevent nursing home placement while still receiving the necessary care that is ordered upon leaving the hospital. The GCM has resources to do just that.

While there are many benefits to healing at home older adults and their families are often unprepared for the challenges that come with it. Careplan’s RN’s and Licensed Social Workers can not only ease those challenges but make the day-to-day routine easier to manage so older adults can focus on the most important thing – getting better.

Why Should You Consider the Hospital to Home Transitions Program for Your Older Adult Clients?

Half of Medicare patients who are re-hospitalized within 30 days haven’t seen a doctor during the entire month, according to a 2009 study in The New England Journal of Medicine of almost 12 million Medicare beneficiaries.

Patients forget up to 80 percent of what health-care providers tell them—and what they do remember is wrong almost half the time, according to a 2003 study in the Journal of The Royal Society of Medicine.

Older people especially have trouble remembering, the study found that Nearly 20 percent of people 65 and older on Medicare are readmitted within 30 days of their initial hospital discharge, according to report in The New England Journal of Medicine.

Nearly 20% of 30-day re-admissions, are likely preventable, and hospital readmission rates are in large part influenced by other factors outside of the hospital domain including poor social support, poverty, and access to outpatient care according to a study in the US National Library of Medicine National Institutes of Health.

The Hospital to Home program consists of: A total of 2-3 Telephonic calls to the senior’s home depending on when the process begins.

Bridget Ritossa, LSW, CMC, Careplan’s Hospital to Home Care Manager worked for many years in hospital and Rehab settings as a discharge planner. Bridget understands what’s necessary for success upon discharge.

  • The first call occurs while the patient is at the hospital and prior to discharge. This allows Careplan’s Hospital to Home GCM access to the senior ‘s care team.  At this time the GCM will set post-discharge goals alongside the hospital discharge planner.   
  • The second and third subsequent calls occur in the home, with family present if able, to review medications, discuss any barriers to care, re-review the discharge plan of care, and to check if follow up appointments with physicians have been made.
  • Home calls are scheduled: 60 minutes for the first call and 30 – 60 minutes for the remaining calls. The senior is encouraged to make a list of questions or concerns to share with the GCM at home visits. During home calls the hospital to Home Geriatric Care Manager (GCM) will see if follow up appointments have been made and transportation is in place. The GCM will check to see that prescriptions are filled and being taken as directed. The GCM will make recommendations for change and provide strategies to further ensure the senior’s safe transition from the hospital.  GCM will make certain all Durable Medical Equipment has arrived. 

The Aging Life Care Professionals at Careplan Geriatric Care Managers developed the Hospital to Home program to provide an opportunity for the senior to transition safely and effectively from their hospital stay to their home. Not only is it the goal to return the senior home successfully but to provide the framework and support to keep the person safe at home for the first 30 days after a discharge as this is the time frame when there is an increased incidence of readmission.

Call Bridget Ritossa, LSW, CMC at  (440) 476-9534 to schedule a no commitment consultation to see if this service could benefit your client or loved one.  Careplan provides services to those locally and across the United States telephonically. 

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